Healthcare Provider Details

I. General information

NPI: 1629035944
Provider Name (Legal Business Name): DEVIN MATTHEW CUNNING M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 MCCULLOCH BLVD N STE. 100
LAKE HAVASU CITY AZ
86403-6559
US

IV. Provider business mailing address

1760 MCCULLOCH BLVD N STE. 100
LAKE HAVASU CITY AZ
86403-6559
US

V. Phone/Fax

Practice location:
  • Phone: 928-854-5368
  • Fax: 928-854-4462
Mailing address:
  • Phone: 928-854-5368
  • Fax: 928-854-4462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number27267
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number27267
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number27267
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number27267
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: