Provider Demographics
NPI:1710164082
Name:CROCCO, STEPHEN
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:CROCCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 E CROSSTIMBERS ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77022-3725
Mailing Address - Country:US
Mailing Address - Phone:713-695-2427
Mailing Address - Fax:713-695-4503
Practice Address - Street 1:747 E CROSSTIMBERS ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77022-3725
Practice Address - Country:US
Practice Address - Phone:713-695-2427
Practice Address - Fax:713-695-2427
Is Sole Proprietor?:No
Enumeration Date:2008-01-29
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047528183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00535997Medicaid