Provider Demographics
NPI:1255547691
Name:COOK, HEATHER IRENE (DO)
Entity type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:IRENE
Last Name:COOK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23500 US HIGHWAY 160
Mailing Address - Street 2:
Mailing Address - City:WALSENBURG
Mailing Address - State:CO
Mailing Address - Zip Code:81089-9524
Mailing Address - Country:US
Mailing Address - Phone:719-738-5100
Mailing Address - Fax:
Practice Address - Street 1:23450 US HIGHWAY 160
Practice Address - Street 2:
Practice Address - City:WALSENBURG
Practice Address - State:CO
Practice Address - Zip Code:81089-8100
Practice Address - Country:US
Practice Address - Phone:719-738-4588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0050479208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP59430064Medicare PIN
MI1255547691Medicaid