Provider Demographics
NPI:1619151727
Name:BRETT L. COCHRUM, MD, PA
Entity Type:Organization
Organization Name:BRETT L. COCHRUM, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:LANDON
Authorized Official - Last Name:COCHRUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-294-4959
Mailing Address - Street 1:6210 JOHN RYAN DR
Mailing Address - Street 2:STE 109A
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4113
Mailing Address - Country:US
Mailing Address - Phone:817-294-4959
Mailing Address - Fax:
Practice Address - Street 1:6210 JOHN RYAN DR
Practice Address - Street 2:STE 109A
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4113
Practice Address - Country:US
Practice Address - Phone:817-294-4959
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2308207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDG9427OtherMEDICARE RR GROUP
TXP00463690OtherMEDICARE RR PTAN
TX00Y334Medicare PIN
TXDG9427OtherMEDICARE RR GROUP
TXP00463690OtherMEDICARE RR PTAN