Provider Demographics
NPI:1780794842
Name:DEETS, CHERYL LYNN CODY (MD)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:LYNN CODY
Last Name:DEETS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:LYNN
Other - Last Name:CODY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:16585 LAKE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-1455
Mailing Address - Country:US
Mailing Address - Phone:763-710-0353
Mailing Address - Fax:
Practice Address - Street 1:16585 LAKE RIDGE DR
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-1455
Practice Address - Country:US
Practice Address - Phone:763-710-0353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38905207V00000X
MN58004207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400175037OtherMEDICARE
MNBD4497764658Medicaid
WI32353300Medicaid
MNBD4497764658Medicaid
WI32353300Medicaid