Healthcare Provider Details

I. General information

NPI: 1275948275
Provider Name (Legal Business Name): MATTHEW COSSACK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PHALEN BLVD
SAINT PAUL MN
55130-5302
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-7500
  • Fax:
Mailing address:
  • Phone: 701-364-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number7191
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2015017084
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number69145
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number63750
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: