Provider Demographics
NPI:1275571754
Name:COOKE, GLEN E (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:E
Last Name:COOKE
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 1:5400 FRANTZ RD STE 250
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-6102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:725 N SANDUSKY AVE STE 3
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-1463
Practice Address - Country:US
Practice Address - Phone:419-562-4966
Practice Address - Fax:419-562-5119
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35065244207RC0000X
OH35-065244207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0945893Medicaid
OHF63677Medicare UPIN
OH0945893Medicaid