Provider Demographics
NPI:1669867099
Name:COCKERELL, JOHN ALLEN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ALLEN
Last Name:COCKERELL
Suffix:
Gender:
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 1:904 AUTUMN ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3741
Mailing Address - Country:US
Mailing Address - Phone:501-227-6363
Mailing Address - Fax:501-227-8629
Practice Address - Street 1:904 AUTUMN ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3741
Practice Address - Country:US
Practice Address - Phone:501-227-6363
Practice Address - Fax:501-227-8629
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR390200000X
ARE-11342207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ART1AR5058Medicaid
AR22848801Medicaid