Provider Demographics
NPI:1033145578
Name:ADEN-WANSBURY, CORY (MD)
Entity type:Individual
Prefix:DR
First Name:CORY
Middle Name:
Last Name:ADEN-WANSBURY
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 1:6151 DARK HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-4866
Mailing Address - Country:US
Mailing Address - Phone:541-512-8814
Mailing Address - Fax:
Practice Address - Street 1:6151 DARK HOLLOW RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-4866
Practice Address - Country:US
Practice Address - Phone:541-512-8814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-25
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22730207YX0602X
ORMD23944261Q00000X, 261QP2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G227300Medicaid
CA00G227300Medicaid
CAA41698Medicare UPIN