Provider Demographics
NPI:1457467797
Name:COOK, SANDRA L (DO)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:COOK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 715067
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-5067
Mailing Address - Country:US
Mailing Address - Phone:440-998-3385
Mailing Address - Fax:440-992-5949
Practice Address - Street 1:517 W PROSPECT RD
Practice Address - Street 2:SUITE C
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-5864
Practice Address - Country:US
Practice Address - Phone:440-998-3385
Practice Address - Fax:440-992-5949
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005601207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0998078Medicaid
OH0773044Medicare PIN
OH0998078Medicaid