Provider Demographics
NPI:1104814912
Name:COOK, J WESLEY (DO)
Entity type:Individual
Prefix:DR
First Name:J
Middle Name:WESLEY
Last Name:COOK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 N RAVENSWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2193
Mailing Address - Country:US
Mailing Address - Phone:773-285-6400
Mailing Address - Fax:773-498-3096
Practice Address - Street 1:5801 W CORCORAN PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644
Practice Address - Country:US
Practice Address - Phone:773-285-6400
Practice Address - Fax:773-498-3096
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36080259207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036080259Medicaid
IL725326OtherHUMANA PROVIDER NUMBER
IL0586501OtherAETNA PROVIDER NUMBER
IL31604484OtherBLUE CROSS BLUE SHIELD
IL036080259Medicaid
IL947831Medicare ID - Type UnspecifiedMEDICARE NUMBER