Provider Demographics
NPI:1295739746
Name:CROCKETT, CATHARINE JEAN (MD)
Entity type:Individual
Prefix:DR
First Name:CATHARINE
Middle Name:JEAN
Last Name:CROCKETT
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 1:1505 EASTLAND DR
Mailing Address - Street 2:STE 2200
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7910
Mailing Address - Country:US
Mailing Address - Phone:309-662-7700
Mailing Address - Fax:309-662-0829
Practice Address - Street 1:1505 EASTLAND DR
Practice Address - Street 2:STE 2200
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7910
Practice Address - Country:US
Practice Address - Phone:309-662-7700
Practice Address - Fax:309-662-0829
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036084217207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036084217Medicaid
IL05700231OtherBC/BS PROVIDER #
IL036084217Medicaid
ILF24350Medicare UPIN
IL180031358Medicare ID - Type UnspecifiedRAILROAD MEDICARE PROV. #
IL0626190001Medicare NSC