1992912695 NPI number — RUSSELL YALE COOKE III OD DOCTOR OF OPTOMET

Table of content: RUSSELL YALE COOKE III OD DOCTOR OF OPTOMET (NPI 1992912695)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992912695 NPI number — RUSSELL YALE COOKE III OD DOCTOR OF OPTOMET

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOKE
Provider First Name:
RUSSELL
Provider Middle Name:
YALE
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
OD DOCTOR OF OPTOMET
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992912695
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2401 CARRIAGE COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIALANTIC
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32903-2448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-777-4400
Provider Business Mailing Address Fax Number:
321-777-4400

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 PLUMOSA STREET
Provider Second Line Business Practice Location Address:
EYEGLASS WORLD
Provider Business Practice Location Address City Name:
MERRITT ISLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-455-2950
Provider Business Practice Location Address Fax Number:
321-455-9719
Provider Enumeration Date:
05/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC001729 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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