MEDICARE: JOHN ROBERT WILLCOCKSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	17563	NE
2	207W00000X	Ophthalmology Physician	0840	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0001010	OTHER	SD	SD WELLMARK BLUE SHIELD I
4	840	OTHER	SD	DAKOTACARE PROVIDER ID
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	22051	OTHER	NE	NE BLUE SHIELD ID

General Provider Information

NPI Number	:	1750384715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN ROBERT WILLCOCKSON M.D.

Provider Business Mailing Address
First Line	:	35025 N. EL SENDERO RD
Second Line	:
City	:	CAVE CREEK
State	:	AZ
Zip	:	85331
Country	:	US
Telephone Number	:	605-661-8495
Fax Number	:	605-665-0526

Provider Business Practice Location Address
First Line	:	35025 N. EL SENDERO RD
Second Line	:
City	:	CAVE CREEK
State	:	AZ
Zip	:	85331
Country	:	US
Telephone Number	:	605-661-8495
Fax Number	:	605-665-0526

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	10/01/2019

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