Healthcare Provider Details

I. General information

NPI: 1114451986
Provider Name (Legal Business Name): MATTHEW COOK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37100 N GANTZEL RD STE 201
SAN TAN VALLEY AZ
85140-7352
US

IV. Provider business mailing address

37100 N GANTZEL RD STE 201
SAN TAN VALLEY AZ
85140-7352
US

V. Phone/Fax

Practice location:
  • Phone: 480-394-4469
  • Fax: 480-394-4520
Mailing address:
  • Phone: 480-394-4469
  • Fax: 480-394-4520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10060975
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number008623
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: