Provider Demographics
NPI:1689775140
Name:COOK, JASON ELLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ELLIS
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 1:1201 W LA VETA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4203
Mailing Address - Country:US
Mailing Address - Phone:714-509-8620
Mailing Address - Fax:714-509-4072
Practice Address - Street 1:1201 W LA VETA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:714-509-8620
Practice Address - Fax:714-509-4072
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA757562080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2104032Medicaid
MAJ28546OtherBCBS MA
MA470153OtherTUFTS HEALTH PLAN
MAA38218Medicare ID - Type Unspecified
MA2104032Medicaid