Healthcare Provider Details

I. General information

NPI: 1437714474
Provider Name (Legal Business Name): CODY JOSEPH ROGERS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2019
Last Update Date: 09/02/2022
Certification Date: 09/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4815 CLEVELAND BLVD
CALDWELL ID
83605-6501
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-455-3545
  • Fax: 208-454-9690
Mailing address:
  • Phone: 208-955-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberO-1707
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: