Provider Demographics
NPI:1255930160
Name:CROCKETT, MAXIMILLIAN SCOTT (OD)
Entity type:Individual
Prefix:
First Name:MAXIMILLIAN
Middle Name:SCOTT
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2876 WILMA RUDOLPH BLVD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5001
Mailing Address - Country:US
Mailing Address - Phone:931-436-9175
Mailing Address - Fax:931-552-1425
Practice Address - Street 1:2876 WILMA RUDOLPH BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5001
Practice Address - Country:US
Practice Address - Phone:931-436-9175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003630152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3733OtherTN STATE LICENSE