Provider Demographics
NPI:1780752022
Name:COOKE, SAM D (OD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:D
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 1:2402 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72501-7421
Mailing Address - Country:US
Mailing Address - Phone:870-793-4681
Mailing Address - Fax:
Practice Address - Street 1:2402 HARRISON ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:AR
Practice Address - Zip Code:72501-7421
Practice Address - Country:US
Practice Address - Phone:870-793-4681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2291152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR102740722Medicaid
AR49652Medicare ID - Type Unspecified
AR102740722Medicaid
ART20329Medicare UPIN
AR0295490001Medicare NSC