Healthcare Provider Details

I. General information

NPI: 1790947117
Provider Name (Legal Business Name): DEIDRE DENISE CROCKER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2390 WALL ST SE
CONYERS GA
30013-2150
US

IV. Provider business mailing address

2390 WALL ST SE
CONYERS GA
30013-2150
US

V. Phone/Fax

Practice location:
  • Phone: 770-922-5696
  • Fax: 770-922-1065
Mailing address:
  • Phone: 770-922-5696
  • Fax: 770-922-1065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number056811
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number056811
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number056811
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: