Provider Demographics
NPI:1487684999
Name:COOKE, COLEENE GWENETH (MD)
Entity Type:Individual
Prefix:
First Name:COLEENE
Middle Name:GWENETH
Last Name:COOKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-3718
Mailing Address - Country:US
Mailing Address - Phone:740-452-9319
Mailing Address - Fax:740-452-2427
Practice Address - Street 1:838 MARKET ST
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-3718
Practice Address - Country:US
Practice Address - Phone:740-452-9319
Practice Address - Fax:740-452-2427
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA370002085R0202X
WI48169-0202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA17335951Medicaid
IA2735951Medicaid
IA30020OtherWELLMARK MAQUOKETA LOCAT
IA30011OtherWELLMARK OFFICE LOCATION
IA0735951Medicaid
IA30009OtherWELLMARK FINLEY LOCATION
WI34754700Medicaid
IA17335951Medicaid
D77851Medicare UPIN
WI0011Medicare ID - Type UnspecifiedWPS
WI34754700Medicaid