Healthcare Provider Details

I. General information

NPI: 1992492409
Provider Name (Legal Business Name): CHARLES MATTHEW COOK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

7703 FLOYD CURL DR
SAN ANTONIO TX
78229-3901
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number37311
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: