Provider Demographics
NPI:1952321002
Name:COOK, JUSTIN O (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:O
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 1:825 NE MULTNOMAH ST
Mailing Address - Street 2:SUITE 1155
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2135
Mailing Address - Country:US
Mailing Address - Phone:503-464-9034
Mailing Address - Fax:503-464-9035
Practice Address - Street 1:2801 N GANTENBEIN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1623
Practice Address - Country:US
Practice Address - Phone:503-413-4870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25848207P00000X
WAM00044892207P00000X
CAA82700207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8433120Medicaid
OR213596Medicaid
I33785Medicare UPIN
OR213596Medicaid
WA8858970Medicare PIN
WA8433120Medicaid