MEDICARE: DR. CHARLES ROBERT COOK D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	G1818	TX

General Provider Information

NPI Number	:	1154364008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES ROBERT COOK D.O.

Provider Business Mailing Address
First Line	:	P.O. BOX 961205
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76161-1205
Country	:	US
Telephone Number	:	817-740-8450
Fax Number	:	817-378-3699

Provider Business Practice Location Address
First Line	:	1701 FOREST RIDGE DR
Second Line	:
City	:	BEDFORD
State	:	TX
Zip	:	76022-7959
Country	:	US
Telephone Number	:	817-545-7700
Fax Number	:	817-545-2298

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	07/21/2022

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