Provider Demographics
NPI:1972510329
Name:COOKE, JOHN KENNETH (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KENNETH
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 1:1119 S 31ST ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-5214
Mailing Address - Country:US
Mailing Address - Phone:254-773-3248
Mailing Address - Fax:866-752-0649
Practice Address - Street 1:1119 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-5214
Practice Address - Country:US
Practice Address - Phone:254-773-3248
Practice Address - Fax:866-752-0649
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5561T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX357178Medicare PIN