Healthcare Provider Details

I. General information

NPI: 1386866051
Provider Name (Legal Business Name): DWAYNE ROBERT COOK I RT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 N CENTER DR SUITE 230
NORFOLK VA
23502-4007
US

IV. Provider business mailing address

PO BOX 2145
CHESAPEAKE VA
23327-2145
US

V. Phone/Fax

Practice location:
  • Phone: 757-466-1163
  • Fax: 757-466-1178
Mailing address:
  • Phone: 757-466-1163
  • Fax: 757-466-1178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number0120002367
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: