Provider Demographics
NPI:1538278445
Name:COOK, TERRY G (OD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:G
Last Name:COOK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:4200 ILBERRY RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6748
Mailing Address - Country:US
Mailing Address - Phone:618-242-6338
Mailing Address - Fax:618-242-0465
Practice Address - Street 1:4200 ILBERRY RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6748
Practice Address - Country:US
Practice Address - Phone:618-242-6338
Practice Address - Fax:618-242-0465
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046006315152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0362200001Medicare NSC
IL293050Medicare PIN
ILT36088Medicare UPIN