Provider Demographics
NPI:1407116965
Name:COKER, CARL BRANYON
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:BRANYON
Last Name:COKER
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 1:91 HORNBEAM RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3026
Mailing Address - Country:US
Mailing Address - Phone:843-476-0434
Mailing Address - Fax:
Practice Address - Street 1:91 HORNBEAM RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3026
Practice Address - Country:US
Practice Address - Phone:843-476-0434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman