Provider Demographics
NPI:1003588732
Name:COOK, DAVITA J (MT)
Entity Type:Individual
Prefix:MS
First Name:DAVITA
Middle Name:J
Last Name:COOK
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4572 KAPP DR
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-5921
Mailing Address - Country:US
Mailing Address - Phone:937-250-9938
Mailing Address - Fax:
Practice Address - Street 1:4572 KAPP DR
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-5921
Practice Address - Country:US
Practice Address - Phone:937-250-9938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1003588732156F00000X, 225500000X, 291U00000X
NY6009038156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0287258Medicaid
OH1003588732OtherCLIA