Provider Demographics
NPI:1073511648
Name:CROTTY, MAUREEN LEE (DPM)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:LEE
Last Name:CROTTY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3627 S HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2227
Mailing Address - Country:US
Mailing Address - Phone:918-494-2902
Mailing Address - Fax:918-494-2905
Practice Address - Street 1:3627 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2227
Practice Address - Country:US
Practice Address - Phone:918-494-2902
Practice Address - Fax:918-494-2905
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK154213ER0200X, 213ES0103X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1720467483OtherDME NPI
OK100780270AMedicaid
OK1720467483OtherDME NPI
T40739Medicare UPIN