Provider Demographics
NPI:1467455774
Name:FAWCETT, CORY (MD)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:
Last Name:FAWCETT
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 1:1600 NW 6TH ST
Mailing Address - Street 2:NORTH SUITE
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1094
Mailing Address - Country:US
Mailing Address - Phone:541-474-5533
Mailing Address - Fax:541-476-2380
Practice Address - Street 1:1600 NW 6TH ST
Practice Address - Street 2:NORTH SUITE
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1094
Practice Address - Country:US
Practice Address - Phone:541-474-5533
Practice Address - Fax:541-476-2380
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18198208600000X
CAG68483208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR057047Medicaid
OR057047Medicaid
ORF07970Medicare UPIN