Provider Demographics
NPI:1992703524
Name:COOK, CHARLES W (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:COOK
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 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4231
Mailing Address - Country:US
Mailing Address - Phone:419-698-7722
Mailing Address - Fax:
Practice Address - Street 1:1050 ISAAC STREETS DR
Practice Address - Street 2:#140
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3291
Practice Address - Country:US
Practice Address - Phone:419-698-7722
Practice Address - Fax:419-698-7723
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350572802080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0711091Medicaid
OHCO0619521Medicare PIN
OH0711091Medicaid