Healthcare Provider Details

I. General information

NPI: 1316174956
Provider Name (Legal Business Name): JOEL CROCKETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20400 LAKE CHABOT RD STE 202
CASTRO VALLEY CA
94546-5315
US

IV. Provider business mailing address

5300 FAR HILLS AVE
DAYTON OH
45429-2381
US

V. Phone/Fax

Practice location:
  • Phone: 510-881-7822
  • Fax: 510-881-8552
Mailing address:
  • Phone: 937-433-7536
  • Fax: 937-433-9612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA150539
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2009016609
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number35.122221
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: