Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 814 | OK |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 814 | OK |
N | 152WL0500X | Optomitrist - Low Vision Rehabilitation | 814 | OK |
NPI | 1346308046 |
---|---|
Provider Name | Phillip Lane Cook |
First Address | Tulsa, OK 74135-2925 |
Second Address | Tulsa, OK 74135-2925 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/12/2006 |
Last Update Date | 15/10/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100790160A | (05) | OK |
20-2565760 | TAX ID (01) | OK |
T40403 | (02) | OK |