Basic Information
| Provider Information | |||||||||
| NPI: | 1639348774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OCKEN | ||||||||
| FirstName: | CARL | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMT | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 13495 GULF BLVD | ||||||||
| Address2: | |||||||||
| City: | MADEIRA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337082515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274182387 | ||||||||
| FaxNumber: | 7273982067 | ||||||||
| Practice Location | |||||||||
| Address1: | 13495 GULF BLVD | ||||||||
| Address2: | |||||||||
| City: | MADEIRA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337082515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274182387 | ||||||||
| FaxNumber: | 7273982067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2008 | ||||||||
| LastUpdateDate: | 02/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | MA15315 | FL | Y | Other Service Providers | Contractor |
ID Information
| ID | Type | State | Issuer | Description | MA15315 | 01 | FL | STATE LICENSE | OTHER |