Provider Demographics
NPI:1477675700
Name:ORTIZ, COOKIE M III
Entity Type:Individual
Prefix:MS
First Name:COOKIE
Middle Name:M
Last Name:ORTIZ
Suffix:III
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 OLD KAW DR
Mailing Address - Street 2:
Mailing Address - City:KAW CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74641-9328
Mailing Address - Country:US
Mailing Address - Phone:580-716-8667
Mailing Address - Fax:
Practice Address - Street 1:201 E CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-4311
Practice Address - Country:US
Practice Address - Phone:580-763-6017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNONE171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator