Healthcare Provider Details

I. General information

NPI: 1538165287
Provider Name (Legal Business Name): JAY ANTON CROCKETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 02/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 BEAR DR
GREENVILLE SC
29605-4458
US

IV. Provider business mailing address

1 INDEPENDENCE PT STE 212
GREENVILLE SC
29615-4536
US

V. Phone/Fax

Practice location:
  • Phone: 864-269-5500
  • Fax: 864-269-8568
Mailing address:
  • Phone: 864-797-6303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number20317
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: