Provider Demographics
NPI:1124255146
Name:COOK, ANGIE BAGHERI (DO)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:BAGHERI
Last Name:COOK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 N. MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411
Mailing Address - Country:US
Mailing Address - Phone:909-884-9091
Mailing Address - Fax:
Practice Address - Street 1:565 N. MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411
Practice Address - Country:US
Practice Address - Phone:909-884-9091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 12050208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics