Basic Information
Provider Information | |||||||||
NPI: | 1720344997 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COOK | ||||||||
FirstName: | DIANA | ||||||||
MiddleName: | CAROLYN GOMEZ | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOMEZ | ||||||||
OtherFirstName: | DIANA | ||||||||
OtherMiddleName: | CAROLYN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2925 BRIARPARK DR STE 575 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770423776 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8326262842 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3200 GREENLAWN BLVD STE 160 | ||||||||
Address2: |   | ||||||||
City: | ROUND ROCK | ||||||||
State: | TX | ||||||||
PostalCode: | 786647591 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2817838162 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/02/2012 | ||||||||
LastUpdateDate: | 09/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207Q00000X | Q5379 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.