MEDICARE: W BRYCE COOK DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	1032580501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1032580501	OTHER	UT	STATE LIC #

General Provider Information

NPI Number	:	1316989569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	W BRYCE COOK DPM

Provider Business Mailing Address
First Line	:	550 E 1400 N
Second Line	:	STE B
City	:	LOGAN
State	:	UT
Zip	:	84341-2406
Country	:	US
Telephone Number	:	435-752-9011
Fax Number	:	435-752-7159

Provider Business Practice Location Address
First Line	:	550 E 1400 N
Second Line	:	STE B
City	:	LOGAN
State	:	UT
Zip	:	84341-2450
Country	:	US
Telephone Number	:	435-752-9011
Fax Number	:	435-752-7159

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	03/07/2023

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Directions to “ W BRYCE COOK DPM” Practice Location

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