Provider Demographics
NPI:1063857753
Name:COOK, BRANDON WADE (MD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:WADE
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:PO BOX 740923
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0923
Mailing Address - Country:US
Mailing Address - Phone:805-860-2153
Mailing Address - Fax:850-315-9350
Practice Address - Street 1:1034 MAR WALT DR UNIT 100
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547
Practice Address - Country:US
Practice Address - Phone:850-860-2153
Practice Address - Fax:850-315-9350
Is Sole Proprietor?:No
Enumeration Date:2013-05-08
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51035207X00000X, 207XS0117X
390200000X
FLME139218207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300014045Medicaid