Provider Demographics
NPI:1417243874
Name:CROCKETT, WESLEY DENNIS (OD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:DENNIS
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7515 SE TUALATIN VALLEY HWY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-8252
Mailing Address - Country:US
Mailing Address - Phone:503-649-7566
Mailing Address - Fax:503-649-0123
Practice Address - Street 1:7515 SE TUALATIN VALLEY HWY
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-8252
Practice Address - Country:US
Practice Address - Phone:503-649-7566
Practice Address - Fax:503-649-0123
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3397ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist