Provider Demographics
NPI:1669448957
Name:CROCKETT, SAMUEL R III (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:R
Last Name:CROCKETT
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-3034
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:1000 E MOUNTAIN BLVD
Practice Address - Street 2:DEPT OF ANESTHESIA
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0027
Practice Address - Country:US
Practice Address - Phone:570-826-7850
Practice Address - Fax:570-826-7855
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD073611L207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001806174Medicaid
PA051323Medicare ID - Type Unspecified