Provider Demographics
NPI:1023542891
Name:PONTIUS, CODY RANDALL (MED, ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:RANDALL
Last Name:PONTIUS
Suffix:
Gender:M
Credentials:MED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 DAVIS PARK RD
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0544
Mailing Address - Country:US
Mailing Address - Phone:904-547-7387
Mailing Address - Fax:904-547-7355
Practice Address - Street 1:460 DAVIS PARK RD
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-0544
Practice Address - Country:US
Practice Address - Phone:904-547-7387
Practice Address - Fax:904-547-7355
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL35842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer