Provider Demographics
NPI:1790796274
Name:COX, DIETHRA D (MD)
Entity Type:Individual
Prefix:
First Name:DIETHRA
Middle Name:D
Last Name:COX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 SOM CENTER RD STE 12123
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-3086
Mailing Address - Country:US
Mailing Address - Phone:440-205-0242
Mailing Address - Fax:440-205-9806
Practice Address - Street 1:5900 SOM CENTER RD STE 12123
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094
Practice Address - Country:US
Practice Address - Phone:440-205-0242
Practice Address - Fax:440-205-9806
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35054360207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0702789Medicaid
OH0702789Medicaid
OHCO7276511Medicare PIN