Provider Demographics
NPI:1811923063
Name:COOKE, SHANNON EUGENE (MD)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:EUGENE
Last Name:COOKE
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 1:1633 COTTONWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-3033
Mailing Address - Country:US
Mailing Address - Phone:325-672-4372
Mailing Address - Fax:325-673-0856
Practice Address - Street 1:1633 COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601
Practice Address - Country:US
Practice Address - Phone:325-672-4372
Practice Address - Fax:325-673-0856
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7972207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S1530OtherBCBS
TX029703802Medicaid
TX8C0212Medicare ID - Type Unspecified
TXG54835Medicare UPIN