Basic Information
Provider Information | |||||||||
NPI: | 1063820231 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COCKAYNE | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | JOHN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | COCKAYNE | ||||||||
OtherFirstName: | TOM | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 3001 GREEN BAY RD | ||||||||
Address2: | PODIATRY | ||||||||
City: | NORTH CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 600643048 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476881900 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | CALIFORNIA AVENUE AT 15TH STREET | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 60608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7735422000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2014 | ||||||||
LastUpdateDate: | 07/31/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 135.000836 | IL | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
No ID Information.