Provider Demographics
NPI:1073698726
Name:CROCKER, LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:
Last Name:CROCKER
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:P O BOX 1123
Mailing Address - Street 2:255 WEST MICHIGAN AVENUE
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49204-1123
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:814 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-2406
Practice Address - Country:US
Practice Address - Phone:321-567-6300
Practice Address - Fax:321-567-6320
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME56993207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12126WMedicare ID - Type Unspecified