Provider Demographics
NPI:1790166734
Name:COOK, EDWIN (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:
Last Name:COOK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3523 SPARROW CT
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691-6437
Mailing Address - Country:US
Mailing Address - Phone:805-279-3625
Mailing Address - Fax:
Practice Address - Street 1:10725 INTERNATIONAL DR
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-7967
Practice Address - Country:US
Practice Address - Phone:805-279-3625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15235152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB269143Medicare UPIN