Provider Demographics
NPI:1710967500
Name:COOK, HOWARD RUSSELL (DO)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:RUSSELL
Last Name:COOK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:H.
Other - Middle Name:RUSSELL
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PC
Mailing Address - Street 1:805 E LEE ST
Mailing Address - Street 2:STE C
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2477
Mailing Address - Country:US
Mailing Address - Phone:334-348-8818
Mailing Address - Fax:334-393-8773
Practice Address - Street 1:805 E LEE ST
Practice Address - Street 2:STE C
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2477
Practice Address - Country:US
Practice Address - Phone:334-348-8818
Practice Address - Fax:334-393-8773
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000014819Medicaid
ALD32739Medicare UPIN
AL000014819Medicaid