Provider Demographics
NPI:1053310367
Name:CROCKER, RODERICK H JR (MD)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:H
Last Name:CROCKER
Suffix:JR
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 1:300 MOUNT AUBURN STREET, SUITE #519
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5600
Mailing Address - Country:US
Mailing Address - Phone:617-547-4400
Mailing Address - Fax:617-576-1076
Practice Address - Street 1:300 MOUNT AUBURN ST
Practice Address - Street 2:STE 519
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-5600
Practice Address - Country:US
Practice Address - Phone:617-547-4400
Practice Address - Fax:617-576-1076
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA55453208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3009700Medicaid
MA3009700Medicaid
MAQX0099Medicare PIN
MAJ07077Medicare PIN