Provider Demographics
NPI:1265501332
Name:COOKE, KYLE A (OD)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:A
Last Name:COOKE
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 1:990 HWY 287 N
Mailing Address - Street 2:SUITE 109
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063
Mailing Address - Country:US
Mailing Address - Phone:817-453-4682
Mailing Address - Fax:817-453-4353
Practice Address - Street 1:990 HWY 287 N
Practice Address - Street 2:SUITE 109
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:817-453-4682
Practice Address - Fax:817-453-4353
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4960TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8A7660Medicare ID - Type Unspecified
U58513Medicare UPIN