Provider Demographics
NPI:1225560675
Name:ROBERTSON, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 KINARD ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:SC
Mailing Address - Zip Code:29108-2967
Mailing Address - Country:US
Mailing Address - Phone:803-405-1900
Mailing Address - Fax:803-405-1919
Practice Address - Street 1:2605 KINARD ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-2967
Practice Address - Country:US
Practice Address - Phone:803-405-1900
Practice Address - Fax:803-405-1919
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC84922207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program