Healthcare Provider Details

I. General information

NPI: 1285636449
Provider Name (Legal Business Name): TERRY R COOK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1478 EAST HWY 162
MONTEZUMA CREEK UT
84534
US

IV. Provider business mailing address

25543 ROAD N.6 LOOP
CORTEZ CO
81321-8404
US

V. Phone/Fax

Practice location:
  • Phone: 435-651-3700
  • Fax:
Mailing address:
  • Phone: 970-565-8660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number540
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number3406870501
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number540
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: