Healthcare Provider Details

I. General information

NPI: 1659370385
Provider Name (Legal Business Name): DIANE S. COOK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2606 PEDDLERS VILLAGE RD SUITE 200
GOSHEN IN
46526-1004
US

IV. Provider business mailing address

2606 PEDDLERS VILLAGE RD SUITE 200
GOSHEN IN
46526-1004
US

V. Phone/Fax

Practice location:
  • Phone: 574-534-6065
  • Fax: 574-534-6037
Mailing address:
  • Phone: 574-534-6065
  • Fax: 574-534-6037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01040345A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: