Provider Demographics
NPI:1932117926
Name:COOK, ROBERT MILTON SR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MILTON
Last Name:COOK
Suffix:SR
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 1:213 N 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401
Mailing Address - Country:US
Mailing Address - Phone:601-545-8004
Mailing Address - Fax:601-545-8004
Practice Address - Street 1:STENNNIS SPACE CENTER SSC MEDICAL CLINIC
Practice Address - Street 2:B1100 RM N180W
Practice Address - City:STENNIS SPACE CENTER
Practice Address - State:MS
Practice Address - Zip Code:39529-6000
Practice Address - Country:US
Practice Address - Phone:228-688-3810
Practice Address - Fax:228-688-7565
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS06176207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115681Medicaid
B30745Medicare UPIN