Provider Demographics
NPI:1073542403
Name:CROCKETT, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:CROCKETT
Suffix:
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:PO BOX 66973
Mailing Address - Street 2:SLOT 303125
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60666-0973
Mailing Address - Country:US
Mailing Address - Phone:877-852-4669
Mailing Address - Fax:
Practice Address - Street 1:150 W HIGH ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1463
Practice Address - Country:US
Practice Address - Phone:815-942-2932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036091397207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL930096984OtherRAILROAD MEDICARE
IL0360913973Medicaid
ILG19156Medicare UPIN
IL0360913973Medicaid