Provider Demographics
NPI:1295363075
Name:MCILVAIN, CODY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:WAYNE
Last Name:MCILVAIN
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 1:777 BANNOCK ST # MC0108
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4597
Mailing Address - Country:US
Mailing Address - Phone:303-602-5176
Mailing Address - Fax:
Practice Address - Street 1:777 BANNOCK ST # MC0108
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4597
Practice Address - Country:US
Practice Address - Phone:303-602-5176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-29
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYTL.7874207P00000X
CODR.0070796207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine