Healthcare Provider Details

I. General information

NPI: 1710245964
Provider Name (Legal Business Name): JOSEPH WILLIAM CROOKSHANK III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 IMPERIAL BLVD
LAKE CHARLES LA
70605-5362
US

IV. Provider business mailing address

501 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5724
US

V. Phone/Fax

Practice location:
  • Phone: 337-721-7236
  • Fax: 337-721-7237
Mailing address:
  • Phone: 337-721-7236
  • Fax: 337-721-7237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number302153
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number302153
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: