Provider Demographics
NPI:1952867012
Name:LONGFELLOW, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:LONGFELLOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 WHITEFOORD AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-2803
Mailing Address - Country:US
Mailing Address - Phone:330-256-8081
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant