Healthcare Provider Details

I. General information

NPI: 1699266791
Provider Name (Legal Business Name): CORY GUNN COSGRAVE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 W SUNSET BLVD STE 94
ST GEORGE UT
84770-6792
US

IV. Provider business mailing address

1930 W SUNSET BLVD STE 94
ST GEORGE UT
84770-6792
US

V. Phone/Fax

Practice location:
  • Phone: 435-709-8786
  • Fax: 435-921-4843
Mailing address:
  • Phone: 435-709-8786
  • Fax: 435-921-4843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS16862
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number7205746-8904
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: