Provider Demographics
NPI:1508993536
Name:CROCKETT, RICHARD E (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:CROCKETT
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 1:1025 MARSH ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4752
Mailing Address - Country:US
Mailing Address - Phone:507-594-4700
Mailing Address - Fax:507-594-5824
Practice Address - Street 1:1025 MARSH ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4752
Practice Address - Country:US
Practice Address - Phone:507-594-4700
Practice Address - Fax:507-594-4700
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN59877207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1508993536Medicaid
IA411236756Medicaid
COG69657Medicare UPIN
014915OtherKAISER-COMMERCIAL NUMBER
CO26978849Medicaid