Provider Demographics
NPI:1619202108
Name:WILSON, CODY R (DO)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:R
Last Name:WILSON
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 1:2380 N 400 E STE C
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1756
Mailing Address - Country:US
Mailing Address - Phone:435-753-7337
Mailing Address - Fax:435-750-6779
Practice Address - Street 1:2380 N 400 E STE C
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1756
Practice Address - Country:US
Practice Address - Phone:435-753-7337
Practice Address - Fax:435-750-6779
Is Sole Proprietor?:No
Enumeration Date:2009-10-16
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8849510-1204208000000X
NE6025208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics