Healthcare Provider Details

I. General information

NPI: 1588658926
Provider Name (Legal Business Name): RANDOLPH B COOKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 11/21/2011
Certification Date:
Deactivation Date: 03/24/2006
Reactivation Date: 04/03/2006

III. Provider practice location address

596 5TH AVE
OWEGO NY
13827-1629
US

IV. Provider business mailing address

346 GRAND AVE
JOHNSON CITY NY
13790-2580
US

V. Phone/Fax

Practice location:
  • Phone: 607-687-7141
  • Fax: 607-687-2224
Mailing address:
  • Phone: 607-729-8156
  • Fax: 607-729-3982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number116682
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number116682
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: