Provider Demographics
NPI:1659382638
Name:COOK, IAN (MD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
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 1:11620 WILSHIRE BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1262
Mailing Address - Country:US
Mailing Address - Phone:310-455-6210
Mailing Address - Fax:310-455-6098
Practice Address - Street 1:11620 WILSHIRE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1262
Practice Address - Country:US
Practice Address - Phone:310-455-6210
Practice Address - Fax:310-455-6098
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG705652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G705650OtherMEDICAL
CAWG70565AMedicare ID - Type Unspecified
CA00G705650OtherMEDICAL