Provider Demographics
NPI:1962907055
Name:COBB, CODY MITCHELL
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:MITCHELL
Last Name:COBB
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 1:129 VISION PARK BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77384-3024
Mailing Address - Country:US
Mailing Address - Phone:936-273-0836
Mailing Address - Fax:713-500-6882
Practice Address - Street 1:129 VISION PARK BLVD STE 109
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77384-3024
Practice Address - Country:US
Practice Address - Phone:936-273-0836
Practice Address - Fax:936-321-2266
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10074081390200000X
390200000X
TXU5664207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program