Provider Demographics
NPI:1982653879
Name:CORDUM, ANN (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:CORDUM
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 1:203 W FORT ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4528
Mailing Address - Country:US
Mailing Address - Phone:208-994-8656
Mailing Address - Fax:888-972-4280
Practice Address - Street 1:203 W FORT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4528
Practice Address - Country:US
Practice Address - Phone:208-994-8656
Practice Address - Fax:888-972-4280
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7030207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F57538Medicare UPIN
1135300Medicare ID - Type Unspecified