Provider Demographics
NPI:1326002775
Name:COOK, WILSON (MD)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:
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 1:120 EXECUTIVE CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-3100
Mailing Address - Country:US
Mailing Address - Phone:540-374-5097
Mailing Address - Fax:540-374-0378
Practice Address - Street 1:120 EXECUTIVE CENTER PKWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3100
Practice Address - Country:US
Practice Address - Phone:540-374-5200
Practice Address - Fax:540-374-1164
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101053911207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5619238Medicaid
VA5619238Medicaid
VA080005482Medicare ID - Type Unspecified