Provider Demographics
NPI:1376908962
Name:COCKLE, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:COCKLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-3505
Mailing Address - Country:US
Mailing Address - Phone:918-786-4434
Mailing Address - Fax:918-786-4435
Practice Address - Street 1:1115 HARBOR RD
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-3505
Practice Address - Country:US
Practice Address - Phone:918-786-4434
Practice Address - Fax:918-786-4435
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK129951175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist