Provider Demographics
NPI:1790315026
Name:CODY TINGLE MD LLC
Entity Type:Organization
Organization Name:CODY TINGLE MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CODY
Authorized Official - Middle Name:
Authorized Official - Last Name:TINGLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-208-1804
Mailing Address - Street 1:PO BOX 19284
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71149-0284
Mailing Address - Country:US
Mailing Address - Phone:318-773-0657
Mailing Address - Fax:
Practice Address - Street 1:535 PIERREMONT RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-2207
Practice Address - Country:US
Practice Address - Phone:318-208-1804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-26
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2189328Medicaid