Provider Demographics
NPI:1144300377
Name:CROCKER, JOHN
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:CROCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 SIMCOE MT. ROAD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98613
Mailing Address - Country:US
Mailing Address - Phone:509-834-1947
Mailing Address - Fax:
Practice Address - Street 1:366 SIMCOE MT. ROAD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:WA
Practice Address - Zip Code:98613
Practice Address - Country:US
Practice Address - Phone:509-834-1947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME016884207Q00000X
WAMD00019205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR119224Medicaid
ORC91007Medicare UPIN
OR119224Medicaid