Provider Demographics
NPI:1811957590
Name:CRONKLETON, MICHAEL AMBROSE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:AMBROSE
Last Name:CRONKLETON
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 1:1505 OLD FREEPORT CT
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-3898
Mailing Address - Country:US
Mailing Address - Phone:563-355-2811
Mailing Address - Fax:
Practice Address - Street 1:1227 E RUSHOLME ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2459
Practice Address - Country:US
Practice Address - Phone:563-421-1000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA22401207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1195909-0215Medicaid
AO 2016Medicare UPIN