Basic Information
| Provider Information | |||||||||
| NPI: | 1598732299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROCKER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DRIVER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11955 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383080132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315415000 | ||||||||
| FaxNumber: | 6142101886 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 SKYLINE DRIVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383013901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315416174 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 04/25/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 36030 | TN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 300130584 | 01 | RR MEDICARE | OTHER | 3873150 | 05 | TN | MEDICAID | 3873151 | 05 | TN | MEDICAID | 3873155 | 05 | TN | MEDICAID | 4035598 | 01 | BCBS | OTHER | 4102197 | 01 | BCBS | OTHER |