Provider Demographics
NPI:1578759304
Name:ELLEFSEN, CODY JOSHUA (DO)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:JOSHUA
Last Name:ELLEFSEN
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 1:203 E DALKE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-8112
Mailing Address - Country:US
Mailing Address - Phone:509-724-0198
Mailing Address - Fax:509-724-0198
Practice Address - Street 1:203 E DALKE AVE STE B
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-8112
Practice Address - Country:US
Practice Address - Phone:509-724-0198
Practice Address - Fax:509-724-0198
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00002282207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8869068Medicare Oscar/Certification