Provider Demographics
NPI:1285335570
Name:COOK, LOGAN
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 GRAND VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46151-5883
Mailing Address - Country:US
Mailing Address - Phone:765-516-6292
Mailing Address - Fax:765-349-7688
Practice Address - Street 1:510 GRAND VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-5883
Practice Address - Country:US
Practice Address - Phone:765-516-6292
Practice Address - Fax:765-349-7688
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1261208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice