Provider Demographics
NPI:1841393766
Name:DE COOK, ROGER EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:EDWARD
Last Name:DE 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 1:500 E 22ND STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6110
Mailing Address - Country:US
Mailing Address - Phone:630-620-8061
Mailing Address - Fax:630-916-7525
Practice Address - Street 1:500 E 22ND STREET
Practice Address - Street 2:SUITE A
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-6110
Practice Address - Country:US
Practice Address - Phone:630-620-8061
Practice Address - Fax:630-916-7525
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-045742173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D14294Medicare UPIN
ILK21636Medicare ID - Type Unspecified