Basic Information
| Provider Information | |||||||||
| NPI: | 1861465601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 HOSPITAL DR | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | CORSICANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751102489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036414895 | ||||||||
| FaxNumber: | 9036414894 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 HOSPITAL DR | ||||||||
| Address2: | STE 210 | ||||||||
| City: | CORSICANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751102489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036414835 | ||||||||
| FaxNumber: | 9036414846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | H9860 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 047015503 | 05 | TX | MEDICAID | 84076X | 01 | TX | BLUE CROSS | OTHER |