Provider Demographics
NPI:1689137762
Name:THORNBURGH, CODY LEE (MD)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:LEE
Last Name:THORNBURGH
Suffix:
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 1:1 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-5276
Mailing Address - Country:US
Mailing Address - Phone:573-882-7901
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL DR # DC069.10
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-3438
Practice Address - Country:US
Practice Address - Phone:573-882-7901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200188422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty