Provider Demographics
NPI:1669522553
Name:COOK, MICHAEL D (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
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 1:14 ALERIA
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-8620
Mailing Address - Country:US
Mailing Address - Phone:949-249-2655
Mailing Address - Fax:949-250-1415
Practice Address - Street 1:265 LAGUNA AVE
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2119
Practice Address - Country:US
Practice Address - Phone:949-494-1892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9227T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP9227BMedicare PIN
CAU44910Medicare UPIN