Provider Demographics
NPI:1437156718
Name:COCHRAN, DOUGLAS R (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:R
Last Name:COCHRAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-1732
Mailing Address - Country:US
Mailing Address - Phone:618-542-6262
Mailing Address - Fax:618-542-6263
Practice Address - Street 1:301 N HICKORY ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1732
Practice Address - Country:US
Practice Address - Phone:618-542-6262
Practice Address - Fax:618-542-6263
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005729111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038005729Medicaid
IL3915223OtherBLUE CROSS BLUE SHIELD IL
IL038005729Medicaid
ILT30650Medicare UPIN