Provider Demographics
NPI:1386325686
Name:COOPER, CROSBY (OD)
Entity type:Individual
Prefix:
First Name:CROSBY
Middle Name:
Last Name:COOPER
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 1:215 S LENA AVE TRLR 13
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3367
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 HERITAGE CIR
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-3744
Practice Address - Country:US
Practice Address - Phone:918-762-2517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3215152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist