=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801803820
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLARKE OCONEE FAMILY MEDICINE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2006
-----------------------------------------------------
Last Update Date | 11/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 SUNSET DR STE 400A
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30606-2293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-353-7747
-----------------------------------------------------
Fax | 706-353-7756
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7336
-----------------------------------------------------
City | ATHENS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30604-7336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-353-7747
-----------------------------------------------------
Fax | 706-353-7756
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | DR. JONATHAN MITCHELL COOK
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 706-353-7747
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 042549
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------