Healthcare Provider Details

I. General information

NPI: 1588408892
Provider Name (Legal Business Name): CODY JAMES ROBERTS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR # DC043.00
COLUMBIA MO
65212-1000
US

IV. Provider business mailing address

1 HOSPITAL DR # DC043.00
COLUMBIA MO
65212-1000
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-1606
  • Fax:
Mailing address:
  • Phone: 573-884-1606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number2024023780
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: