Provider Demographics
NPI:1790727642
Name:COOK, BRIAN W (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:W
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:PO BOX 17308
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33762-0308
Mailing Address - Country:US
Mailing Address - Phone:904-482-1070
Mailing Address - Fax:904-482-1077
Practice Address - Street 1:2560 N MCMULLEN BOOTH RD
Practice Address - Street 2:STE B
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-4182
Practice Address - Country:US
Practice Address - Phone:727-726-1962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0083573207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06039OtherBLUE SHIELD OF FL
FL264873300Medicaid
E65849Medicare UPIN
FL264873300Medicaid