Provider Demographics
NPI:1790340693
Name:MOON, CODY D (DPT/ ATC)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:D
Last Name:MOON
Suffix:
Gender:M
Credentials:DPT/ ATC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4301 W MARKHAM ST # 783
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7101
Mailing Address - Country:US
Mailing Address - Phone:501-686-8000
Mailing Address - Fax:501-526-5148
Practice Address - Street 1:10815 COLONEL GLENN RD STE 500
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-8041
Practice Address - Country:US
Practice Address - Phone:501-406-9201
Practice Address - Fax:501-320-7813
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2025-08-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO20180169712255A2300X
2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer