Provider Demographics
NPI:1386738920
Name:COOK-GLENN, CELESTE LOIS (MD)
Entity type:Individual
Prefix:DR
First Name:CELESTE
Middle Name:LOIS
Last Name:COOK-GLENN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 AUDUBON CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6910
Mailing Address - Country:US
Mailing Address - Phone:601-607-3145
Mailing Address - Fax:601-607-3145
Practice Address - Street 1:413 AUDUBON CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6910
Practice Address - Country:US
Practice Address - Phone:601-607-3145
Practice Address - Fax:601-607-3145
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16062207ZP0102X
ALMD.28467207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSG80418Medicare UPIN