Healthcare Provider Details

I. General information

NPI: 1316009079
Provider Name (Legal Business Name): KAREN ELIZABETH CROCKETT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10566 N HWY 191
ELFRIDA AZ
85610-9021
US

IV. Provider business mailing address

1205 F AVENUE
DOUGLAS AZ
85607
US

V. Phone/Fax

Practice location:
  • Phone: 520-642-2222
  • Fax: 520-364-4261
Mailing address:
  • Phone: 520-364-1429
  • Fax: 520-364-4261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36374
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: