Provider Demographics
NPI:1487009734
Name:WALTHALL, CODY A (MD)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:A
Last Name:WALTHALL
Suffix:
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 1:1109 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CUERO
Mailing Address - State:TX
Mailing Address - Zip Code:77954-2108
Mailing Address - Country:US
Mailing Address - Phone:361-275-2800
Mailing Address - Fax:361-275-8791
Practice Address - Street 1:1109 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CUERO
Practice Address - State:TX
Practice Address - Zip Code:77954
Practice Address - Country:US
Practice Address - Phone:361-275-2800
Practice Address - Fax:361-275-8791
Is Sole Proprietor?:No
Enumeration Date:2016-04-24
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS2925207Q00000X
ARE-10831207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX842333OtherMEDICARE
TX400778302Medicaid
TXS2925OtherSTATE LIC