Provider Demographics
NPI:1407817752
Name:COOK, MARK F (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:F
Last Name:COOK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53038-9504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:412 HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:JOHNSON CREEK
Practice Address - State:WI
Practice Address - Zip Code:53038-9504
Practice Address - Country:US
Practice Address - Phone:920-390-9038
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2358-035152WC0802X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38724000Medicaid
WI38724000Medicaid