Provider Demographics
NPI:1982865317
Name:COOK, JEREMY WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:WILLIAM
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 1:60 PLATO BLVD E
Mailing Address - Street 2:SUITE270
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-1827
Mailing Address - Country:US
Mailing Address - Phone:651-209-1600
Mailing Address - Fax:651-291-9169
Practice Address - Street 1:587 BIELENBERG DR
Practice Address - Street 2:SUITE 200
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4451
Practice Address - Country:US
Practice Address - Phone:651-578-2700
Practice Address - Fax:651-578-7077
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52654207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1982865317Medicaid
MN070001000Medicare PIN