Provider Demographics
NPI:1912233875
Name:WELDON COOKE MD LLC
Entity Type:Organization
Organization Name:WELDON COOKE MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER- MD
Authorized Official - Prefix:
Authorized Official - First Name:WELDON
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:COOKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACS
Authorized Official - Phone:219-871-2500
Mailing Address - Street 1:3965 N. MALAGA DR
Mailing Address - Street 2:
Mailing Address - City:LAPORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350
Mailing Address - Country:US
Mailing Address - Phone:219-873-1777
Mailing Address - Fax:219-873-0001
Practice Address - Street 1:10176 W. 400 NORTH
Practice Address - Street 2:SUITE C
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360
Practice Address - Country:US
Practice Address - Phone:219-873-1777
Practice Address - Fax:219-873-0001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-28
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01020627B207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D94864Medicare UPIN
210100AMedicare PIN
IN210100Medicare PIN