Provider Demographics
NPI:1740287549
Name:COCKERELL, CHARLES FREDERICK (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:FREDERICK
Last Name:COCKERELL
Suffix:
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 1:205 W R D MIZE RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014-2518
Mailing Address - Country:US
Mailing Address - Phone:816-228-4770
Mailing Address - Fax:816-228-1156
Practice Address - Street 1:205 W R D MIZE RD
Practice Address - Street 2:SUITE 304
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2518
Practice Address - Country:US
Practice Address - Phone:816-228-4770
Practice Address - Fax:816-228-1156
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9052208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
07973031OtherBLUE CROSS/BLUE SHIELD
312720OtherFIRST GUARD
1208133OtherUNITED HEALTH CARE
202400OtherFAMILY HEALTH PARTNERS
4001376OtherAETNA
202401OtherFAMILY HEALTH PARTNERS
MO200110211Medicaid