Healthcare Provider Details

I. General information

NPI: 1225282882
Provider Name (Legal Business Name): DAVID J. CROCKETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 02/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 E CHANDLER BLVD SUITE 202
PHOENIX AZ
85048-7645
US

IV. Provider business mailing address

2222 E HIGHLAND AVE SUITE 204
PHOENIX AZ
85016-4872
US

V. Phone/Fax

Practice location:
  • Phone: 480-659-2330
  • Fax: 480-659-2544
Mailing address:
  • Phone: 602-264-4834
  • Fax: 602-254-5178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number49273
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number49273
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: