Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | P4149 | TX |
N | 207PE0004X | Emergency Medical Services | P4149 | TX |
N | 208D00000X | General Practice Physician | P4149 | TX |
NPI | 1184614661 |
---|---|
Provider Name | Dr. Cord Wayne Cunningham |
First Address | Georgetown, TX 78633-4362 |
Second Address | Fort Hood, TX 76544-5095 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/10/2005 |
Last Update Date | 02/12/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
FC1769679 | DEA (01) | |
P4149 | TEXAS MEDICAL LICENSE (01) | TX |