Healthcare Provider Details

I. General information

NPI: 1073732541
Provider Name (Legal Business Name): DOUGLAS WAYNE COOK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 PALMETTO RD
RAYVILLE LA
71269-6415
US

IV. Provider business mailing address

213 EAST FRENCHMAN'S BEND ROAD
MONROE LA
71203
US

V. Phone/Fax

Practice location:
  • Phone: 318-728-2970
  • Fax:
Mailing address:
  • Phone: 318-410-8031
  • Fax: 318-728-2272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number15129
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number015129
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: