Provider Demographics
NPI:1770931628
Name:YODER, CORY GWYNNDOLYNN (DO)
Entity type:Individual
Prefix:DR
First Name:CORY
Middle Name:GWYNNDOLYNN
Last Name:YODER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1550
Mailing Address - Country:US
Mailing Address - Phone:606-784-3771
Mailing Address - Fax:606-783-6847
Practice Address - Street 1:316 W 2ND ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351
Practice Address - Country:US
Practice Address - Phone:606-784-3771
Practice Address - Fax:606-783-6847
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY04376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY04376OtherKY MEDICAL LICENSE