MEDICARE: CODY R WILSON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	8849510-1204	UT
2	208000000X	Pediatrics Physician	6025	NE

General Provider Information

NPI Number	:	1619202108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CODY R WILSON D.O.

Provider Business Mailing Address
First Line	:	2380 N 400 E STE C
Second Line	:
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341-1756
Country	:	US
Telephone Number	:	435-753-7337
Fax Number	:	435-750-6779

Provider Business Practice Location Address
First Line	:	2380 N 400 E STE C
Second Line	:
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341-1756
Country	:	US
Telephone Number	:	435-753-7337
Fax Number	:	435-750-6779

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2009
Last Update Date	:	10/02/2019

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Directions to “ CODY R WILSON D.O.” Practice Location

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