Provider Demographics
NPI:1053810127
Name:RODRIGUEZ, CODY
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:RODRIGUEZ
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 1:1240 FOREST PARK DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-2804
Mailing Address - Country:US
Mailing Address - Phone:405-204-6165
Mailing Address - Fax:
Practice Address - Street 1:6551 HARRIS PKWY STE 250
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-6115
Practice Address - Country:US
Practice Address - Phone:817-263-6116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX805416363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology