Provider Demographics
NPI:1336287572
Name:MICHEAL G COOK OD PC
Entity Type:Organization
Organization Name:MICHEAL G COOK OD PC
Other - Org Name:EYEAR OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-349-1660
Mailing Address - Street 1:3044 GOODMAN RD E
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-8760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3044 GOODMAN RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-8760
Practice Address - Country:US
Practice Address - Phone:662-349-1660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016295Medicaid
MS1306010001Medicare NSC
MSDN0869Medicare PIN
MS09016295Medicaid
MS512G700124Medicare PIN