Basic Information
| Provider Information | |||||||||
| NPI: | 1215921564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOKOSKA | ||||||||
| FirstName: | MIKEL | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOKOSKA | ||||||||
| OtherFirstName: | MICHAEL | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 16111 COPELAND FARMS ROAD | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138176547 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8102 CITRUS PARK TOWN CENTER | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139266288 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 05/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC2472 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 084741100 | 05 | FL | MEDICAID | 180016475 | 01 | FL | RR MEDICARE | OTHER | 931211 | 01 | FL | HUMANA VCP | OTHER | 13062 | 01 | FL | HERITAGE | OTHER | 18630 | 01 | FL | SPECTERA | OTHER | 22871 | 01 | FL | UNITED HEALTH GROUP VISION PLANS | OTHER | 931211 | 01 | FL | EYEMED | OTHER |