Provider Demographics
NPI:1851480230
Name:CROCKER, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:CROCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MIDLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-8104
Mailing Address - Country:US
Mailing Address - Phone:843-851-5015
Mailing Address - Fax:843-851-5029
Practice Address - Street 1:225 MIDLAND PKWY
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-8104
Practice Address - Country:US
Practice Address - Phone:843-851-5015
Practice Address - Fax:843-851-5029
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9308174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD18329Medicare UPIN