Basic Information
Provider Information | |||||||||
NPI: | 1619150349 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AULL | ||||||||
FirstName: | CODY | ||||||||
MiddleName: | BOYD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2839 | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | MS | ||||||||
PostalCode: | 393022839 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6017033480 | ||||||||
FaxNumber: | 6017030124 | ||||||||
Practice Location | |||||||||
Address1: | 1521 A 22ND AVENUE | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | MS | ||||||||
PostalCode: | 393014016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6017038360 | ||||||||
FaxNumber: | 6017038369 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/17/2007 | ||||||||
LastUpdateDate: | 07/01/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 23702 | MS | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207YS0123X | 23702 | MS | N |   | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery |
ID Information
ID | Type | State | Issuer | Description | 2007034875 | 01 | MO | STATE OF MISSOURI | OTHER |