Provider Demographics
NPI:1457991697
Name:OLIVER, CODY BRYAN (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:BRYAN
Last Name:OLIVER
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75799-6600
Mailing Address - Country:US
Mailing Address - Phone:903-565-5742
Mailing Address - Fax:
Practice Address - Street 1:3900 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75799-6600
Practice Address - Country:US
Practice Address - Phone:903-565-5742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT76352081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty