Provider Demographics
NPI:1497743843
Name:DAVIS, CODY W (DO)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:W
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 40D
Mailing Address - Street 2:
Mailing Address - City:ELLSINORE
Mailing Address - State:MO
Mailing Address - Zip Code:63937-9705
Mailing Address - Country:US
Mailing Address - Phone:573-593-4157
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 40D
Practice Address - Street 2:
Practice Address - City:ELLSINORE
Practice Address - State:MO
Practice Address - Zip Code:63937-9705
Practice Address - Country:US
Practice Address - Phone:573-593-4157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002002010207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOD93541Medicare UPIN