Healthcare Provider Details

I. General information

NPI: 1760488951
Provider Name (Legal Business Name): JOE D COPE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 S MUSKOGEE AVE
TAHLEQUAH OK
74464-5439
US

IV. Provider business mailing address

2010 S MUSKOGEE AVE
TAHLEQUAH OK
74464-5439
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-0020
  • Fax: 918-453-0020
Mailing address:
  • Phone: 918-456-0020
  • Fax: 918-453-0020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number917
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100764330A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: