Provider Demographics
NPI:1083488084
Name:WILBURN, CODY B (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:B
Last Name:WILBURN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 INNOVATION PKWY STE 135
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-3602
Mailing Address - Country:US
Mailing Address - Phone:317-956-1082
Mailing Address - Fax:
Practice Address - Street 1:1260 INNOVATION PKWY STE 135
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-3602
Practice Address - Country:US
Practice Address - Phone:317-956-1082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05015324A225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist