Provider Demographics
NPI:1386160455
Name:GILLISS, CODY VINCENT (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:CODY
Middle Name:VINCENT
Last Name:GILLISS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 PUALEI CIR APT 210
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815-4942
Mailing Address - Country:US
Mailing Address - Phone:808-892-8999
Mailing Address - Fax:
Practice Address - Street 1:3030 PUALEI CIR APT 210
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96815-4942
Practice Address - Country:US
Practice Address - Phone:808-892-8999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-20
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI4614225100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty