Provider Demographics
NPI:1609817378
Name:COOKE, CAROLYN JEAN (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JEAN
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 1:203 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-4208
Mailing Address - Country:US
Mailing Address - Phone:659-739-2947
Mailing Address - Fax:765-973-9233
Practice Address - Street 1:25 W MAIN ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:IN
Practice Address - Zip Code:47102
Practice Address - Country:US
Practice Address - Phone:812-794-8100
Practice Address - Fax:812-794-8200
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056482A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200392240Medicaid
INP00046422OtherRAILROAD MEDICARE
IN200392240Medicaid
IN201550EMedicare PIN