Provider Demographics
NPI:1326074113
Name:COOK, AUDRA K (MD)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:K
Last Name:COOK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:K
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 N MONTE VISTA ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-7213
Mailing Address - Country:US
Mailing Address - Phone:580-453-3156
Mailing Address - Fax:580-453-3157
Practice Address - Street 1:201 N MONTE VISTA ST
Practice Address - Street 2:SUITE C
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-7213
Practice Address - Country:US
Practice Address - Phone:580-453-3156
Practice Address - Fax:580-453-3157
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22996207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200004740Medicaid
OKH99293Medicare UPIN
OK200004740Medicaid