Provider Demographics
NPI:1528071958
Name:COOKE, JOHN W (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:COOKE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 N BAY ST
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-2937
Mailing Address - Country:US
Mailing Address - Phone:352-357-3107
Mailing Address - Fax:352-357-9971
Practice Address - Street 1:633 N BAY ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-2937
Practice Address - Country:US
Practice Address - Phone:352-357-3107
Practice Address - Fax:352-357-9971
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS-4437207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82596ZMedicare ID - Type Unspecified
D60679Medicare UPIN