Healthcare Provider Details

I. General information

NPI: 1265758460
Provider Name (Legal Business Name): JOHN A CROCKETT MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2010
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 LA CASA VIA STE 100
WALNUT CREEK CA
94598-4863
US

IV. Provider business mailing address

210 LA COLINA DR
ALAMO CA
94507-1816
US

V. Phone/Fax

Practice location:
  • Phone: 925-519-2866
  • Fax: 925-692-5522
Mailing address:
  • Phone: 925-519-2866
  • Fax: 925-692-5522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG230620
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG230620
License Number StateCA

VIII. Authorized Official

Name: KARL F STEMMLER
Title or Position: CREDENTIALER
Credential: MPA
Phone: 619-258-6200