Provider Demographics
NPI:1740325240
Name:DIETHRA D. COX, M.D., INC.
Entity type:Organization
Organization Name:DIETHRA D. COX, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIETHRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-205-0242
Mailing Address - Street 1:9485 MENTOR AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4597
Mailing Address - Country:US
Mailing Address - Phone:440-205-0242
Mailing Address - Fax:
Practice Address - Street 1:9485 MENTOR AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4597
Practice Address - Country:US
Practice Address - Phone:440-205-0242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-4360-C207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0702789Medicaid
OH0702789Medicaid
OH6181070001Medicare NSC
OH0736603Medicare ID - Type Unspecified