Provider Demographics
NPI:1801107636
Name:CROCKETT, DAVID G (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:G
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 1:139 S 40TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68131-3003
Mailing Address - Country:US
Mailing Address - Phone:402-595-3939
Mailing Address - Fax:402-595-3898
Practice Address - Street 1:985100 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-5100
Practice Address - Country:US
Practice Address - Phone:402-559-2909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-26
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6264207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine