Healthcare Provider Details

I. General information

NPI: 1467433904
Provider Name (Legal Business Name): JACK B COOK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 HILLSIDE AVE
WILLISTON PARK NY
11596-2102
US

IV. Provider business mailing address

305 HILLSIDE AVE
WILLISTON PARK NY
11596-2102
US

V. Phone/Fax

Practice location:
  • Phone: 516-747-4011
  • Fax: 516-747-1277
Mailing address:
  • Phone: 516-747-4011
  • Fax: 516-747-1277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number127282
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: