Healthcare Provider Details

I. General information

NPI: 1083654701
Provider Name (Legal Business Name): MATTHEW DAVID CROOKSTON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 PLEASANT VALLEY DR
LEAGUE CITY TX
77573-4430
US

IV. Provider business mailing address

301 UNIVERSITY BLVD
GALVESTON TX
77555-5302
US

V. Phone/Fax

Practice location:
  • Phone: 713-894-7104
  • Fax:
Mailing address:
  • Phone: 409-772-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5719TG
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: