Basic Information
| Provider Information | |||||||||
| NPI: | 1750369203 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COOK CHILDREN'S PHYSICIAN NETWORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 733784 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753733784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828851860 | ||||||||
| FaxNumber: | 6828851396 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828856800 | ||||||||
| FaxNumber: | 6828856729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | DZURIK | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, CCPN | ||||||||
| AuthorizedOfficialTelephone: | 6828851416 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.