Provider Demographics
NPI:1992912695
Name:COOKE, RUSSELL YALE III (OD DOCTOR OF OPTOMET)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:YALE
Last Name:COOKE
Suffix:III
Gender:M
Credentials:OD DOCTOR OF OPTOMET
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2401 CARRIAGE COURT
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-2448
Mailing Address - Country:US
Mailing Address - Phone:321-777-4400
Mailing Address - Fax:321-777-4400
Practice Address - Street 1:100 PLUMOSA STREET
Practice Address - Street 2:EYEGLASS WORLD
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952
Practice Address - Country:US
Practice Address - Phone:321-455-2950
Practice Address - Fax:321-455-9719
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001729152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PIN20363Medicare ID - Type Unspecified