Provider Demographics
NPI:1023175882
Name:COOK, WRAY (BCO)
Entity type:Individual
Prefix:
First Name:WRAY
Middle Name:
Last Name:COOK
Suffix:
Gender:M
Credentials:BCO
Other - Prefix:
Other - First Name:BRUCE
Other - Middle Name:
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BCO
Mailing Address - Street 1:2821 N BALLAS RD
Mailing Address - Street 2:SUITE C30
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2321
Mailing Address - Country:US
Mailing Address - Phone:314-567-7585
Mailing Address - Fax:314-567-7083
Practice Address - Street 1:2821 N BALLAS RD STE C30
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2393
Practice Address - Country:US
Practice Address - Phone:314-567-7585
Practice Address - Fax:314-567-7083
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO86-198-10156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO321966905Medicaid
MO321966905Medicaid