Provider Demographics
NPI:1124425376
Name:WILLIAMS, CODY
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:WILLIAMS
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 1:2198 OLD GROVELAND RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:GA
Mailing Address - Zip Code:31321-3322
Mailing Address - Country:US
Mailing Address - Phone:760-445-1924
Mailing Address - Fax:
Practice Address - Street 1:2198 OLD GROVELAND RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:GA
Practice Address - Zip Code:31321-3322
Practice Address - Country:US
Practice Address - Phone:760-445-1924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman