Provider Demographics
NPI:1588658926
Name:COOKE, RANDOLPH B (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:B
Last Name:COOKE
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:596 5TH AVE
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-1629
Practice Address - Country:US
Practice Address - Phone:607-687-7141
Practice Address - Fax:607-687-2224
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2011-11-21
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
NY116682174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC9632Medicare PIN