Provider Demographics
NPI:1437169851
Name:CROCKER, PETER D (DC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:D
Last Name:CROCKER
Suffix:
Gender:M
Credentials:DC
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 97
Mailing Address - Street 2:
Mailing Address - City:PORT BYRON
Mailing Address - State:IL
Mailing Address - Zip Code:61275-0097
Mailing Address - Country:US
Mailing Address - Phone:309-848-9017
Mailing Address - Fax:888-830-9748
Practice Address - Street 1:106 N HIGH ST
Practice Address - Street 2:
Practice Address - City:PORT BYRON
Practice Address - State:IL
Practice Address - Zip Code:61275-9532
Practice Address - Country:US
Practice Address - Phone:309-848-9017
Practice Address - Fax:888-830-9748
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5854111N00000X
IL038012184111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2194521OtherFIRST HEALTH
AZ2050841OtherUNITED HEALTHCARE
AZU72874Medicare UPIN
AZZ73325Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER