Provider Demographics
NPI:1457360679
Name:COOK, MICHAEL G (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
Last Name:COOK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3044 GOODMAN ROAD EAST
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-8760
Mailing Address - Country:US
Mailing Address - Phone:662-349-1660
Mailing Address - Fax:662-349-1663
Practice Address - Street 1:3044 GOODMAN ROAD EAST
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-8760
Practice Address - Country:US
Practice Address - Phone:662-349-1660
Practice Address - Fax:662-349-1663
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS467152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880118Medicaid
T20804Medicare UPIN
MS00880118Medicaid
MS1306010001Medicare NSC
MS512I410037Medicare PIN