Provider Demographics
NPI:1053986059
Name:PATTERSON, CODY E (DO)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:E
Last Name:PATTERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 N 4TH AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-269-7147
Mailing Address - Fax:208-416-6522
Practice Address - Street 1:151 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-269-7147
Practice Address - Fax:208-416-6522
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMRO-2046207Q00000X
ID01861207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine