Provider Demographics
NPI:1922019199
Name:CROCKFORD, JON L (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:L
Last Name:CROCKFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:880 KEMPSVILLE RD
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3931
Mailing Address - Country:US
Mailing Address - Phone:757-466-6350
Mailing Address - Fax:757-422-9262
Practice Address - Street 1:880 KEMPSVILLE RD
Practice Address - Street 2:SUITE 2200
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3931
Practice Address - Country:US
Practice Address - Phone:757-466-6350
Practice Address - Fax:757-422-9262
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101229832207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA160001321Medicare PIN