Provider Demographics
NPI:1285754077
Name:CODY, MATTHEW ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:ROBERT
Last Name:CODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 107
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-0107
Mailing Address - Country:US
Mailing Address - Phone:231-922-9270
Mailing Address - Fax:231-922-9271
Practice Address - Street 1:1105 SIXTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2345
Practice Address - Country:US
Practice Address - Phone:231-922-9270
Practice Address - Fax:231-922-9271
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088741207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2081349OtherFACILITY FQHC MEDICAID #