Provider Demographics
NPI:1740217629
Name:CODY, THORNTON SQUIRE (MD)
Entity Type:Individual
Prefix:
First Name:THORNTON
Middle Name:SQUIRE
Last Name:CODY
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 1:368 RIVER STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-2242
Mailing Address - Country:US
Mailing Address - Phone:802-886-2526
Mailing Address - Fax:802-886-2225
Practice Address - Street 1:368 RIVER STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-2242
Practice Address - Country:US
Practice Address - Phone:802-886-2526
Practice Address - Fax:802-886-2225
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0007413207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0002655Medicaid
NH30001422Medicaid
VT2655Medicare ID - Type Unspecified
NH30001422Medicaid