Provider Demographics
NPI:1871697409
Name:CO,, EDDY D (MD)
Entity type:Individual
Prefix:
First Name:EDDY
Middle Name:D
Last Name:CO,
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 1:3267 S 16TH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4500
Mailing Address - Country:US
Mailing Address - Phone:414-645-0920
Mailing Address - Fax:
Practice Address - Street 1:3267 S 16TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4500
Practice Address - Country:US
Practice Address - Phone:414-645-0920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19814207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30914600Medicaid
WI061917005OtherRAILROAD MEDICARE
WI30914600Medicaid
WI000073996Medicare ID - Type UnspecifiedMEDICARE