Provider Demographics
NPI:1245222322
Name:WASNER, CODY KEITH (MD)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:KEITH
Last Name:WASNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 EXECUTIVE PKWY
Mailing Address - Street 2:STE 300
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2192
Mailing Address - Country:US
Mailing Address - Phone:541-683-0710
Mailing Address - Fax:541-683-0712
Practice Address - Street 1:1200 EXECUTIVE PKWY
Practice Address - Street 2:STE 300
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2192
Practice Address - Country:US
Practice Address - Phone:541-683-0710
Practice Address - Fax:541-683-0712
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12537207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR228395Medicaid
OR228395Medicaid
C94031Medicare UPIN
OR228395Medicaid