Healthcare Provider Details

I. General information

NPI: 1053808964
Provider Name (Legal Business Name): CAROLYN ELIZABETH COOKSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3298
US

IV. Provider business mailing address

101 THE CITY DR S
ORANGE CA
92868-3298
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-5770
  • Fax:
Mailing address:
  • Phone: 714-456-5770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA174518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: