Provider Demographics
NPI:1558328377
Name:CODY, DOUGLAS THANE ROMNEY II (MD)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:THANE ROMNEY
Last Name:CODY
Suffix:II
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:PO BOX 1100
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-1100
Mailing Address - Country:US
Mailing Address - Phone:417-505-7114
Mailing Address - Fax:417-853-5302
Practice Address - Street 1:1115 ALASKA ST STE 214
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2014
Practice Address - Country:US
Practice Address - Phone:417-505-7114
Practice Address - Fax:417-853-5302
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA31264207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP00449774OtherRR MC MSC
MO2019029148OtherSTATE LICENSE
IA1558328377Medicaid
IA3141838Medicaid
IA3141838Medicaid
IL$$$$$$$$$Medicaid
IA15718Medicare ID - Type Unspecified
ILK47285Medicare PIN