Provider Demographics
NPI:1699014084
Name:MADISON, CODY SR
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:
Last Name:MADISON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16732 CREST VLY
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6802
Mailing Address - Country:US
Mailing Address - Phone:405-706-4281
Mailing Address - Fax:
Practice Address - Street 1:10948 N MAY AVE STE B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-6224
Practice Address - Country:US
Practice Address - Phone:405-751-8889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid