1417243874 NPI number — DR. WESLEY DENNIS CROCKETT O.D.

Table of content: DR. WESLEY DENNIS CROCKETT O.D. (NPI 1417243874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417243874 NPI number — DR. WESLEY DENNIS CROCKETT O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROCKETT
Provider First Name:
WESLEY
Provider Middle Name:
DENNIS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417243874
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7515 SE TUALATIN VALLEY HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILLSBORO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97123-8252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-649-7566
Provider Business Mailing Address Fax Number:
503-649-0123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1610 S WHITE MOUNTAIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHOW LOW
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85901-7106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-537-3937
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3397ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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