Provider Demographics
NPI:1750418117
Name:COOK, TIMOTHY L (OPTICIAN)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:L
Last Name:COOK
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:PA
Mailing Address - Zip Code:16428-1339
Mailing Address - Country:US
Mailing Address - Phone:814-725-4531
Mailing Address - Fax:
Practice Address - Street 1:68 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH EAST
Practice Address - State:PA
Practice Address - Zip Code:16428-1339
Practice Address - Country:US
Practice Address - Phone:814-725-4531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0759590001Medicare ID - Type Unspecified