Provider Demographics
NPI:1013943984
Name:COX, JACK L JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:L
Last Name:COX
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:PO BOX 2048
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-2048
Mailing Address - Country:US
Mailing Address - Phone:318-251-3620
Mailing Address - Fax:318-255-6604
Practice Address - Street 1:925 N TRENTON ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3327
Practice Address - Country:US
Practice Address - Phone:318-251-3620
Practice Address - Fax:318-255-6604
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA016321207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1337048Medicaid
LAB60753Medicare UPIN
LA5K155CU42Medicare PIN