Provider Demographics
NPI:1205080512
Name:GLENN M COCHRAN OD PLLC
Entity type:Organization
Organization Name:GLENN M COCHRAN OD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:MORGAN
Authorized Official - Last Name:COCHRAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:601-776-6988
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:303 S ARCHUSA AVE
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-13
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSDS0535OtherRAILROAD MEDICARE
MS07088019Medicaid
MS302G704960Medicare PIN
MS6620380001Medicare NSC