Healthcare Provider Details

I. General information

NPI: 1528466091
Provider Name (Legal Business Name): WELDON COOKE MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2014
Last Update Date: 12/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10176 W 400 N SUITE C
MICHIGAN CITY IN
46360-9008
US

IV. Provider business mailing address

10176 W 400 N SUITE C
MICHIGAN CITY IN
46360-9008
US

V. Phone/Fax

Practice location:
  • Phone: 219-873-1777
  • Fax: 219-873-0001
Mailing address:
  • Phone: 219-873-1777
  • Fax: 219-873-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number01020627A
License Number StateIN

VIII. Authorized Official

Name: TINA J BOWMAR
Title or Position: ADMIN
Credential:
Phone: 219-221-7287