Provider Demographics
NPI:1073539300
Name:MCCROSSEN, PATRICK G (DDS MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:G
Last Name:MCCROSSEN
Suffix:
Gender:M
Credentials:DDS MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7828
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70010-7828
Mailing Address - Country:US
Mailing Address - Phone:504-451-6423
Mailing Address - Fax:
Practice Address - Street 1:4502 LOUISIANA HWY 951
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:LA
Practice Address - Zip Code:70748
Practice Address - Country:US
Practice Address - Phone:225-634-0413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA19928207R00000X
MS15060207R00000X
LA3309122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02481083Medicaid
MS5121840003Medicare NSC
D87515Medicare UPIN