Provider Demographics
NPI:1619944287
Name:COCHRAN, GLENN M (OD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:M
Last Name:COCHRAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39355-0690
Mailing Address - Country:US
Mailing Address - Phone:601-776-6988
Mailing Address - Fax:601-776-6989
Practice Address - Street 1:303 S ARCHUSA AVE
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:MS
Practice Address - Zip Code:39355-0690
Practice Address - Country:US
Practice Address - Phone:601-776-6988
Practice Address - Fax:601-776-6989
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS488152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00087907Medicaid
MS00087907Medicaid
MS302I414966Medicare PIN