Provider Demographics
NPI:1710932199
Name:SKROCKI, JAMES A (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:SKROCKI
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:DEPT 2018
Mailing Address - Street 2:PO BOX 29675
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77 W. FOREST AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1482
Practice Address - Country:US
Practice Address - Phone:928-773-2515
Practice Address - Fax:928-773-2240
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ310852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ773285Medicaid
AZ773285Medicaid
H32495Medicare UPIN
AZZ79101Medicare PIN
AZP00213379Medicare PIN