Provider Demographics
NPI:1942997150
Name:YOUNGMAN, CODY JARRETT (SOIDC)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:JARRETT
Last Name:YOUNGMAN
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 PADDLEWHEEL RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-0332
Mailing Address - Country:US
Mailing Address - Phone:618-318-5440
Mailing Address - Fax:
Practice Address - Street 1:BLDG 3655 GREEN STREET
Practice Address - Street 2:
Practice Address - City:OKINAWA
Practice Address - State:JAPAN
Practice Address - Zip Code:96310
Practice Address - Country:JP
Practice Address - Phone:618-318-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC07219559CY1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman