Provider Demographics
NPI:1912043605
Name:COCKERHAM EYE CONSULTANTS PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:COCKERHAM EYE CONSULTANTS PROFESSIONAL CORPORATION
Other - Org Name:ENVISAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:P
Authorized Official - Last Name:COCKERHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-873-7801
Mailing Address - Street 1:23052 ALICIA PKWY STE 619
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-1643
Mailing Address - Country:US
Mailing Address - Phone:657-284-2178
Mailing Address - Fax:
Practice Address - Street 1:3590 CAMINO DEL RIO N STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1707
Practice Address - Country:US
Practice Address - Phone:619-810-1275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86885207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty