Provider Demographics
NPI:1952343816
Name:COOK, GLENDON E (MD)
Entity Type:Individual
Prefix:
First Name:GLENDON
Middle Name:E
Last Name: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 1:16 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:PA
Mailing Address - Zip Code:18612-1136
Mailing Address - Country:US
Mailing Address - Phone:570-675-2111
Mailing Address - Fax:570-675-6545
Practice Address - Street 1:16 CHURCH ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:PA
Practice Address - Zip Code:18612-1136
Practice Address - Country:US
Practice Address - Phone:570-675-2111
Practice Address - Fax:570-675-6545
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD428346L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000063294OtherBLUESHIELD
PA101764792-0001Medicaid
PA824355OtherFPH
PA000000266485OtherUNISON
PA000000266485OtherUNISON
PA824355OtherFPH
PA102659ZDEEMedicare PIN