Provider Demographics
NPI:1619539913
Name:MAULDIN, CODY DREW (DPT)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:DREW
Last Name:MAULDIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2965 E TARPON DR STE 150
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9007
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:
Practice Address - Street 1:3955 E 12TH ST STE 150
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3114
Practice Address - Country:US
Practice Address - Phone:307-554-7861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-1883225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist