Basic Information
| Provider Information | |||||||||
| NPI: | 1740287549 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COCKERELL | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | FREDERICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 W R D MIZE RD | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | BLUE SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640142518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162284770 | ||||||||
| FaxNumber: | 8162281156 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 W R D MIZE RD | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | BLUE SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640142518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162284770 | ||||||||
| FaxNumber: | 8162281156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 08/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | R9052 | MO | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 07973031 | 01 | BLUE CROSS/BLUE SHIELD | OTHER | 312720 | 01 | FIRST GUARD | OTHER | 1208133 | 01 | UNITED HEALTH CARE | OTHER | 202400 | 01 | FAMILY HEALTH PARTNERS | OTHER | 4001376 | 01 | AETNA | OTHER | 202401 | 01 | FAMILY HEALTH PARTNERS | OTHER | 200110211 | 05 | MO | MEDICAID |