Healthcare Provider Details

I. General information

NPI: 1992703524
Provider Name (Legal Business Name): CHARLES W COOK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 ISAAC STREETS DR #140
OREGON OH
43616-3291
US

IV. Provider business mailing address

4235 SECOR RD
TOLEDO OH
43623-4231
US

V. Phone/Fax

Practice location:
  • Phone: 419-698-7722
  • Fax: 419-698-7723
Mailing address:
  • Phone: 419-698-7722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number35057280
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: