Provider Demographics
NPI:1134221021
Name:CROCKETT, JOHN A (MD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:A
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 1:240 LA CASA VIA STE 100
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-4863
Mailing Address - Country:US
Mailing Address - Phone:925-519-2866
Mailing Address - Fax:925-692-5522
Practice Address - Street 1:240 LA CASA VIA STE 100
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-4863
Practice Address - Country:US
Practice Address - Phone:925-519-2866
Practice Address - Fax:925-692-5522
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG230620207V00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG230620Medicare ID - Type Unspecified
CAA41831Medicare UPIN