Provider Demographics
NPI:1497867949
Name:COOK, RUSSEL CLIFFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSEL
Middle Name:CLIFFORD
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 1:411 ALDERSON RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3101
Mailing Address - Country:US
Mailing Address - Phone:252-946-4134
Mailing Address - Fax:252-946-2432
Practice Address - Street 1:1206 BROWN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-4671
Practice Address - Country:US
Practice Address - Phone:252-946-4134
Practice Address - Fax:252-946-2432
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23686208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC24043OtherBCBS
NC8924043Medicaid
NC8924043Medicaid