Healthcare Provider Details

I. General information

NPI: 1053752907
Provider Name (Legal Business Name): BENJAMIN BRYAN COOK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 E BUSCH BLVD
TAMPA FL
33617
US

IV. Provider business mailing address

PO BOX 207151
DALLAS TX
75320-7151
US

V. Phone/Fax

Practice location:
  • Phone: 813-979-2929
  • Fax:
Mailing address:
  • Phone: 636-200-4393
  • Fax: 636-527-0766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-100289
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberODP-100289
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC-4823
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC-4823
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: