Provider Demographics
NPI:1093840977
Name:COOK, ROLAND EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:ROLAND
Middle Name:EDWARD
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 1:10123 SE MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2532
Mailing Address - Country:US
Mailing Address - Phone:503-251-6129
Mailing Address - Fax:503-261-6649
Practice Address - Street 1:10123 SE MARKET ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2532
Practice Address - Country:US
Practice Address - Phone:503-251-6129
Practice Address - Fax:503-261-6649
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD09228207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR030762Medicaid
220033179Medicare PIN
ORR112986Medicare PIN