Provider Demographics
NPI:1528466091
Name:WELDON COOKE MD LLC
Entity type:Organization
Organization Name:WELDON COOKE MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOWMAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-221-7287
Mailing Address - Street 1:10176 W 400 N
Mailing Address - Street 2:SUITE C
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-9008
Mailing Address - Country:US
Mailing Address - Phone:219-873-1777
Mailing Address - Fax:219-873-0001
Practice Address - Street 1:10176 W 400 N
Practice Address - Street 2:SUITE C
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-9008
Practice Address - Country:US
Practice Address - Phone:219-873-1777
Practice Address - Fax:219-873-0001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01020627A261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care