Provider Demographics
NPI:1174528632
Name:WHITBOURNE-COOKE, INGRID S (OD)
Entity type:Individual
Prefix:DR
First Name:INGRID
Middle Name:S
Last Name:WHITBOURNE-COOKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:INGRID
Other - Middle Name:
Other - Last Name:WHITBOURNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:8252 NW 15TH CT
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-6211
Mailing Address - Country:US
Mailing Address - Phone:954-706-2037
Mailing Address - Fax:
Practice Address - Street 1:3001 N STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-1913
Practice Address - Country:US
Practice Address - Phone:954-733-2066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2017-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3064152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU65502Medicare UPIN
FL620243800Medicaid
FL20771Medicare ID - Type Unspecified