Provider Demographics
NPI:1780645697
Name:CROCKETT, GEOFFREY MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:MATTHEW
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:PO BOX 30180
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0180
Mailing Address - Country:US
Mailing Address - Phone:435-658-7000
Mailing Address - Fax:
Practice Address - Street 1:900 ROUND VALLEY DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7552
Practice Address - Country:US
Practice Address - Phone:435-658-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5848509-1205207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD6280Medicaid
UT005567239Medicare ID - Type Unspecified5475 S 500 E, OGDEN
UT005568356Medicare ID - Type Unspecified3460 PIONEER PKWY, WVC
UT005568449Medicare ID - Type Unspecified3580 W 9000 S, W JORDAN
UT005568641Medicare ID - Type Unspecified1050 E SOUTH TEMPLE, SLC
UT005568556Medicare ID - Type Unspecified630 MEDICAL DR, BOUNTIFUL
UTI37027Medicare UPIN
UT005567145Medicare ID - Type Unspecified1600 ANTELOPE DR, LAYTON
UTD6280Medicaid