Provider Demographics
NPI:1669867099
Name:COCKERELL, JOHN ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALLEN
Last Name:COCKERELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:A
Other - Last Name:COCKERELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1400 N HUGHES ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-6113
Mailing Address - Country:US
Mailing Address - Phone:903-277-3295
Mailing Address - Fax:
Practice Address - Street 1:5423 L ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-1726
Practice Address - Country:US
Practice Address - Phone:903-277-3295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-11342207Q00000X
AR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ART1AR5058Medicaid