Provider Demographics
NPI:1346261989
Name:COBB, RUDY THEODORE (MD)
Entity Type:Individual
Prefix:DR
First Name:RUDY
Middle Name:THEODORE
Last Name:COBB
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 1:305 COLLEGE ST W
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-2911
Mailing Address - Country:US
Mailing Address - Phone:931-433-2488
Mailing Address - Fax:931-433-2489
Practice Address - Street 1:305 COLLEGE ST W
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-2911
Practice Address - Country:US
Practice Address - Phone:931-433-2488
Practice Address - Fax:931-433-2489
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNM0011699208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3004292Medicaid
TN40011699OtherUNITEDHEATHCARE
TN34725OtherBCBS OF TN
TN61195OtherBCBS OF AL
TN3004292Medicaid
TN61195OtherBCBS OF AL