Provider Demographics
NPI:1760478218
Name:CROCKETT, WILLIAM B (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:B
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 6TH AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8820
Mailing Address - Country:US
Mailing Address - Phone:941-782-4259
Mailing Address - Fax:941-782-4101
Practice Address - Street 1:5942 34TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3683
Practice Address - Country:US
Practice Address - Phone:941-782-4860
Practice Address - Fax:941-782-4899
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME630642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377289600Medicaid
G08635Medicare UPIN
FL377289600Medicaid