Provider Demographics
NPI:1821191149
Name:COCKRELL, WILEY T JR (MD)
Entity Type:Individual
Prefix:
First Name:WILEY
Middle Name:T
Last Name:COCKRELL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 DREXEL RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27803-2167
Mailing Address - Country:US
Mailing Address - Phone:252-443-4349
Mailing Address - Fax:252-246-7684
Practice Address - Street 1:3001 FIRESTONE PKWY NE
Practice Address - Street 2:MEDICAL DEPARTMENT
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-7996
Practice Address - Country:US
Practice Address - Phone:252-246-7607
Practice Address - Fax:252-246-7684
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38915207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8923204Medicaid
NC23204OtherBCBS PROVIDER NUMBER
B10121Medicare UPIN
NC23204OtherBCBS PROVIDER NUMBER