Healthcare Provider Details

I. General information

NPI: 1619202108
Provider Name (Legal Business Name): CODY R WILSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2009
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 N 400 E STE C
NORTH LOGAN UT
84341-1756
US

IV. Provider business mailing address

2380 N 400 E STE C
NORTH LOGAN UT
84341-1756
US

V. Phone/Fax

Practice location:
  • Phone: 435-753-7337
  • Fax: 435-750-6779
Mailing address:
  • Phone: 435-753-7337
  • Fax: 435-750-6779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number8849510-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6025
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: