Provider Demographics
NPI:1871023960
Name:ANDERSON, CODY CLARKE (DPM)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:CLARKE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-519-2399
Mailing Address - Fax:843-519-0234
Practice Address - Street 1:241 KELLEY ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2446
Practice Address - Country:US
Practice Address - Phone:843-519-2399
Practice Address - Fax:843-519-0234
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2022-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT061.0000023213ES0103X
SC713213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCJ236Medicaid