Provider Demographics
NPI:1447964614
Name:COOL, MATTHEW JAMES
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:COOL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 POLARIS ST BLDG 586
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23461-1935
Mailing Address - Country:US
Mailing Address - Phone:757-862-0060
Mailing Address - Fax:
Practice Address - Street 1:472 POLARIS ST BLDG 586
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23461-1935
Practice Address - Country:US
Practice Address - Phone:757-862-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
1437528940OtherDEPARTMENT OF DEFENSE TRICARE