Provider Demographics
NPI:1386768588
Name:COOKE, GERALD L (MD)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:L
Last Name:COOKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4906 S GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-2816
Mailing Address - Country:US
Mailing Address - Phone:773-936-5376
Mailing Address - Fax:
Practice Address - Street 1:6127 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-5894
Practice Address - Country:US
Practice Address - Phone:708-444-2310
Practice Address - Fax:888-509-9868
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-109316208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-109316Medicaid