Healthcare Provider Details

I. General information

NPI: 1982692034
Provider Name (Legal Business Name): JIMMY D CODY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 04/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 W 9TH ST
TULSA OK
74127-9020
US

IV. Provider business mailing address

DEPT. 672
TULSA OK
74182-0001
US

V. Phone/Fax

Practice location:
  • Phone: 918-587-2561
  • Fax:
Mailing address:
  • Phone: 866-321-8433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number2338
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: