Basic Information
| Provider Information | |||||||||
| NPI: | 1225282882 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROCKETT | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 E HIGHLAND AVE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022644834 | ||||||||
| FaxNumber: | 6022545178 | ||||||||
| Practice Location | |||||||||
| Address1: | 4545 E CHANDLER BLVD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850487645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806592330 | ||||||||
| FaxNumber: | 4806592544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2008 | ||||||||
| LastUpdateDate: | 02/15/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 49273 | AZ | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207YP0228X | 49273 | AZ | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 922449 | 05 | AZ | MEDICAID |