Provider Demographics
NPI:1083177455
Name:JINNETTE, CODY MITCHEL (DO)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:MITCHEL
Last Name:JINNETTE
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 W MICHIGAN ST # CL630
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1120 W MICHIGAN ST # CL630
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5209
Practice Address - Country:US
Practice Address - Phone:317-278-2689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-11
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02006968A207R00000X, 207RI0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1104197523OtherANTHEM PTAN
IN300092620Medicaid