Provider Demographics
NPI:1376702241
Name:CROCKETT, REBECCA ELIZABETH (DO)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:ELIZABETH
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7590 AUBURN RD STE 14
Mailing Address - Street 2:
Mailing Address - City:CONCORD TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44077-9176
Mailing Address - Country:US
Mailing Address - Phone:440-354-1899
Mailing Address - Fax:440-354-1845
Practice Address - Street 1:5105 SOM CENTER ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094
Practice Address - Country:US
Practice Address - Phone:440-602-6710
Practice Address - Fax:440-269-8107
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.009381207V00000X
OH58.001481207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2867858Medicaid
OH4241891Medicare PIN
OH2867858Medicaid