Provider Demographics
NPI:1861475899
Name:COOKE, RANDOLPH D (PHD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:D
Last Name:COOKE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HOSPITAL ROAD
Mailing Address - Street 2:FAMILY MEDICINE CLINIC
Mailing Address - City:FT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5650
Mailing Address - Country:US
Mailing Address - Phone:706-787-0232
Mailing Address - Fax:
Practice Address - Street 1:300 HOSPITAL RD
Practice Address - Street 2:FAMILY MEDICINE CLINIC
Practice Address - City:FT. GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905
Practice Address - Country:US
Practice Address - Phone:706-787-9352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3124103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical