Provider Demographics
NPI:1164551636
Name:MARK COCKLEY, LLC
Entity Type:Organization
Organization Name:MARK COCKLEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:M
Authorized Official - Last Name:COCKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-824-5063
Mailing Address - Street 1:1 TURTLE CREEK CIR
Mailing Address - Street 2:STE. F
Mailing Address - City:SWANTON
Mailing Address - State:OH
Mailing Address - Zip Code:43558-8537
Mailing Address - Country:US
Mailing Address - Phone:419-825-5151
Mailing Address - Fax:419-825-5901
Practice Address - Street 1:1 TURTLE CREEK CIR
Practice Address - Street 2:STE. F
Practice Address - City:SWANTON
Practice Address - State:OH
Practice Address - Zip Code:43558-8537
Practice Address - Country:US
Practice Address - Phone:419-825-5151
Practice Address - Fax:419-825-5901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9318901Medicare PIN