Healthcare Provider Details

I. General information

NPI: 1639229594
Provider Name (Legal Business Name): MATTHEW DAVIS COBB DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 10/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8080 ACADEMY RD NE STE C
ALBUQUERQUE NM
87111-1159
US

IV. Provider business mailing address

8080 ACADEMY RD NE STE C
ALBUQUERQUE NM
87111-1159
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-4164
  • Fax: 505-247-4561
Mailing address:
  • Phone: 505-247-4164
  • Fax: 505-247-4561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberEL1620
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number325
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: