Provider Demographics
NPI:1073699039
Name:COONEY, KATHLEEN A (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:COONEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 SO. 500 EAST #600
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1971
Mailing Address - Country:US
Mailing Address - Phone:801-587-6705
Mailing Address - Fax:801-715-8228
Practice Address - Street 1:1950 CIRCLE OF HOPE
Practice Address - Street 2:CLINIC 2B
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5550
Practice Address - Country:US
Practice Address - Phone:801-585-0100
Practice Address - Fax:801-585-0721
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9691669-1205207R00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2790720Medicaid
MI0H17613361Medicare ID - Type Unspecified
MIF04726Medicare UPIN