Provider Demographics
NPI:1962406900
Name:COOK, JOHN R (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:COOK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 WOODSIDE EXECUTIVE CT
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-3809
Mailing Address - Country:US
Mailing Address - Phone:803-644-8900
Mailing Address - Fax:803-644-8995
Practice Address - Street 1:2110 WOODSIDE EXECUTIVE CT
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-3809
Practice Address - Country:US
Practice Address - Phone:803-644-8900
Practice Address - Fax:803-644-8995
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11685207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCE929440282OtherMCR/MCCORMICK OFFICE
SCGP2477Medicaid
E929440281Medicare ID - Type Unspecified
SCGP2477Medicaid