Provider Demographics
NPI:1700974938
Name:COCHRAN, JACK D (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:COCHRAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:770 MAGNOLIA AVE
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879
Mailing Address - Country:US
Mailing Address - Phone:951-737-0110
Mailing Address - Fax:951-737-5944
Practice Address - Street 1:770 MAGNOLIA AVE
Practice Address - Street 2:SUITE 2C
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879
Practice Address - Country:US
Practice Address - Phone:951-737-0110
Practice Address - Fax:951-737-5944
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA029440207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A294400Medicare ID - Type Unspecified
A25768Medicare UPIN