1265758460 NPI number — JOHN A CROCKETT MD A PROFESSIONAL CORPORATION

Table of content: (NPI 1265758460)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265758460 NPI number — JOHN A CROCKETT MD A PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN A CROCKETT MD A PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JOHN A CROCKETT MD, A PROFESSIONAL CORPORATION
Provider Other Organization Name Type Code:
3
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:
1265758460
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 LA COLINA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALAMO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94507-1816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-519-2866
Provider Business Mailing Address Fax Number:
925-692-5522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 LA CASA VIA STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALNUT CREEK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94598-4863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-519-2866
Provider Business Practice Location Address Fax Number:
925-692-5522
Provider Enumeration Date:
04/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
STEMMLER
Authorized Official First Name:
KARL
Authorized Official Middle Name:
F
Authorized Official Title or Position:
CREDENTIALER
Authorized Official Telephone Number:
619-258-6200

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  G230620 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207V00000X , with the licence number: G230620 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1134221021 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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