Provider Demographics
NPI:1629075296
Name:COOK, SAMIR ISSA (MD)
Entity Type:Individual
Prefix:
First Name:SAMIR
Middle Name:ISSA
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 1:56 TOWER CIRCLE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503
Mailing Address - Country:US
Mailing Address - Phone:606-677-2913
Mailing Address - Fax:606-677-6983
Practice Address - Street 1:56 TOWER CIRCLE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503
Practice Address - Country:US
Practice Address - Phone:606-677-2913
Practice Address - Fax:606-677-6983
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY34871207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64384712Medicaid
KY65933517Medicaid
KY0696901Medicare ID - Type UnspecifiedWAYNE CO. CLINIC, IND
KY65933517Medicaid
KY64384712Medicaid