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
State | License ID | Taxonomies |
---|---|---|
OR | MD09228 | 207ZC0500X, 207ZP0102X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No | 207ZC0500X | Allopathic & Osteopathic Physicians | Pathology | Cytopathology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | 030762 | Medicaid | |
220033179 | Medicare PIN | ||
OR | R112986 | Medicare PIN |