Provider Demographics
NPI:1225158314
Name:COCKRELL EYECARE CENTER
Entity Type:Organization
Organization Name:COCKRELL EYECARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:COCKRELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-372-1715
Mailing Address - Street 1:534 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74058-2036
Mailing Address - Country:US
Mailing Address - Phone:918-762-2573
Mailing Address - Fax:918-762-2574
Practice Address - Street 1:534 ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-2036
Practice Address - Country:US
Practice Address - Phone:918-762-2573
Practice Address - Fax:918-762-2574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100768620BMedicaid
C05037OtherRAILROAD MEDICARE
OK600522010Medicare ID - Type Unspecified
OK100768620BMedicaid