Provider Demographics
NPI:1760481816
Name:CROCKER, DAVID A (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:CROCKER
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 1:6325 DIGITAL WAY
Mailing Address - Street 2:SUITE 480
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1678
Mailing Address - Country:US
Mailing Address - Phone:317-275-5005
Mailing Address - Fax:
Practice Address - Street 1:6325 DIGITAL WAY
Practice Address - Street 2:SUITE 480
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1678
Practice Address - Country:US
Practice Address - Phone:317-275-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV208052085R0202X
IN01062616A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000501707OtherANTHEM
IN1760481816Medicaid
WV1812489000Medicaid
WV1812489000Medicaid
WVCR4111351Medicare PIN