Provider Demographics
NPI:1063145357
Name:WINDOM, CEDRIC BERNARD II (MD)
Entity type:Individual
Prefix:
First Name:CEDRIC
Middle Name:BERNARD
Last Name:WINDOM
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOSPITAL DR # 58.00
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65212-1000
Mailing Address - Country:US
Mailing Address - Phone:573-882-4438
Mailing Address - Fax:573-884-9992
Practice Address - Street 1:1 HOSPITAL DR # 58.00
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-1000
Practice Address - Country:US
Practice Address - Phone:573-882-4438
Practice Address - Fax:573-884-9992
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022024908208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics