Provider Demographics
NPI:1093009920
Name:COCKERELL, JERRY D (DO)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:D
Last Name:COCKERELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 72 BOX 329
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-8521
Mailing Address - Country:US
Mailing Address - Phone:580-564-2446
Mailing Address - Fax:
Practice Address - Street 1:HC 72 BOX 329
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439-8521
Practice Address - Country:US
Practice Address - Phone:580-564-2446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2853207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery