Provider Demographics
NPI:1053501437
Name:PAYNE, CODY ROBERT (PT)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:ROBERT
Last Name:PAYNE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3613 NW 56TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4526
Mailing Address - Country:US
Mailing Address - Phone:405-948-8686
Mailing Address - Fax:405-978-8603
Practice Address - Street 1:3613 NW 56TH ST
Practice Address - Street 2:SUITE 202
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4526
Practice Address - Country:US
Practice Address - Phone:405-948-8686
Practice Address - Fax:405-978-8603
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4021225100000X
TX1197631225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200132560AMedicaid
OK4021OtherSTATE LICENSE
OK402218Medicare PIN