Provider Demographics
NPI:1508042516
Name:COOK, RUSSELL (RT)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:COOK
Suffix:
Gender:M
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 S. LEMON AVE. STE 249
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789
Mailing Address - Country:US
Mailing Address - Phone:714-403-8515
Mailing Address - Fax:714-669-4088
Practice Address - Street 1:385 S. LEMON AVE. STE 249
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789
Practice Address - Country:US
Practice Address - Phone:714-403-8515
Practice Address - Fax:714-669-4088
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-21
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHM-6244247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR059983OtherMEDICARE
CAR059983OtherMEDICARE