Provider Demographics
NPI:1871538942
Name:COBB, CAROLYN LOUISE (MD)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:LOUISE
Last Name:COBB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-3114
Mailing Address - Country:US
Mailing Address - Phone:918-747-5188
Mailing Address - Fax:
Practice Address - Street 1:550 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-3820
Practice Address - Country:US
Practice Address - Phone:918-588-1900
Practice Address - Fax:918-582-6405
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12692207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100257340-BMedicaid