Provider Demographics
NPI:1750384715
Name:WILLCOCKSON, JOHN ROBERT (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:WILLCOCKSON
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 1:35025 N. EL SENDERO RD
Mailing Address - Street 2:
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331
Mailing Address - Country:US
Mailing Address - Phone:605-661-8495
Mailing Address - Fax:605-665-0526
Practice Address - Street 1:35025 N. EL SENDERO RD
Practice Address - Street 2:
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331
Practice Address - Country:US
Practice Address - Phone:605-661-8495
Practice Address - Fax:605-665-0526
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17563207W00000X
SD0840207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE36-305015-14Medicaid
NE36-3050195-12Medicaid
SD0001010OtherSD WELLMARK BLUE SHIELD I
SD840OtherDAKOTACARE PROVIDER ID
SD6300040Medicaid
NE36-3050195-18Medicaid
NE22051OtherNE BLUE SHIELD ID
NE36-305015-14Medicaid
SD0001010OtherSD WELLMARK BLUE SHIELD I
NE36-3050195-12Medicaid