Provider Demographics
NPI:1912074741
Name:COOK, DAVID BRYAN (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRYAN
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 1:1340 S. AMMON ROAD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406
Mailing Address - Country:US
Mailing Address - Phone:208-523-3141
Mailing Address - Fax:
Practice Address - Street 1:1340 S. AMMON ROAD
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83406
Practice Address - Country:US
Practice Address - Phone:208-523-3141
Practice Address - Fax:208-525-2661
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-840152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000852600Medicaid
ID000852600Medicaid
ID1592159Medicare PIN
IDU25027Medicare UPIN