Provider Demographics
NPI:1376605535
Name:CROCKETT, DAVID SHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:SHAN
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1745 SAN FELIPE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-2540
Mailing Address - Country:US
Mailing Address - Phone:831-636-1884
Mailing Address - Fax:831-636-1775
Practice Address - Street 1:911 SUNSET DR
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-5602
Practice Address - Country:US
Practice Address - Phone:831-637-5771
Practice Address - Fax:831-638-9040
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG210022084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G210022Medicare ID - Type Unspecified