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General NPI Number Information
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NPI Number | 1376605535
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Entity Type | Individual
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Provider Name | DAVID SHAN CROCKETT MD
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Gender | Male
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Dates
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Enumeration Date | 12/14/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 911 SUNSET DR
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City | HOLLISTER
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State | CA
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Zip | 95023-5602
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Country | US
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Telephone | 831-637-5771
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Fax | 831-638-9040
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Provider Business Mailing Address
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Address Line | 1745 SAN FELIPE RD STE 1
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City | HOLLISTER
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State | CA
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Zip | 95023-2540
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Country | US
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Telephone | 831-636-1884
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Fax | 831-636-1775
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0805X
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Taxonomy Name | Geriatric Psychiatry Physician
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License Number | G21002
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License Number State | CA
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