Provider Demographics
NPI:1659370385
Name:COOK, DIANE S (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:S
Last Name:COOK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2606 PEDDLERS VILLAGE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-1004
Mailing Address - Country:US
Mailing Address - Phone:574-534-6065
Mailing Address - Fax:574-534-6037
Practice Address - Street 1:2606 PEDDLERS VILLAGE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-1004
Practice Address - Country:US
Practice Address - Phone:574-534-6065
Practice Address - Fax:574-534-6037
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2011-10-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01040345A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100114420AMedicaid
IN100114420AMedicaid
E52699Medicare UPIN