Provider Demographics
NPI:1356580542
Name:CROCKER, ROBERT LEON (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEON
Last Name:CROCKER
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 1:4264 E RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-6100
Mailing Address - Country:US
Mailing Address - Phone:601-421-9177
Mailing Address - Fax:
Practice Address - Street 1:4264 E RIDGE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-6100
Practice Address - Country:US
Practice Address - Phone:601-421-9177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08720207Q00000X
CAA70404207Q00000X
CT040080207Q00000X
DEC1-0006033207Q00000X
HI11849207Q00000X
KY36653207Q00000X
MO118044207Q00000X
MT9902207Q00000X
NH11127207Q00000X
NJ25MA07091200207Q00000X
NC200001571207Q00000X
ND8386207Q00000X
OK22710207Q00000X
TNMD12756207Q00000X
VT042-0010301207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine