=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932637956
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL COOK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2017
-----------------------------------------------------
Last Update Date | 06/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 921 NE 13TH ST
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73104-5007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-922-2773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3005 JAMIN PAUL CIR
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-8075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-922-2773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0002X
-----------------------------------------------------
Taxonomy Name | Hospice and Palliative Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 33189
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------