1467433904 NPI number — JACK B COOK MD

Table of content: JACK B COOK MD (NPI 1467433904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467433904 NPI number — JACK B COOK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOK
Provider First Name:
JACK
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467433904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
305 HILLSIDE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLISTON PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11596-2102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-747-4011
Provider Business Mailing Address Fax Number:
516-747-1277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 HILLSIDE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLISTON PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11596-2102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-747-4011
Provider Business Practice Location Address Fax Number:
516-747-1277
Provider Enumeration Date:
11/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  127282 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 127282 . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00351368 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2C3455 . This is a "HEALTHNET" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 42Z652 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 16240 . This is a "VYTRA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0098910 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0344848 . This is a "CIGNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: AS708 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2209991 . This is a "US HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: JC042Z6520 . This is a "GENERIC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4313878 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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