Basic Information
| Provider Information | |||||||||
| NPI: | 1053752907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | BRYAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 207151 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753207151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270766 | ||||||||
| Practice Location | |||||||||
| Address1: | 5201 E BUSCH BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139792929 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2013 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | ODP-100289 | ID | N | Eye and Vision Services Providers | Optometrist | 152WC0802X | ODP-100289 | ID | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WC0802X | OPC-4823 | FL | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152W00000X | OPC-4823 | FL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.