Provider Demographics
NPI:1942203203
Name:COOK, LISA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:COOK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 W NOBLE AVE
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-2116
Mailing Address - Country:US
Mailing Address - Phone:405-260-2020
Mailing Address - Fax:405-282-8886
Practice Address - Street 1:2114 W NOBLE AVE
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-2116
Practice Address - Country:US
Practice Address - Phone:405-260-2020
Practice Address - Fax:405-282-8886
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2032152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100763900AMedicaid
410034238OtherRAILROAD MEDICARE
OK100763900AMedicaid