Provider Demographics
NPI:1811990765
Name:CROCKER, PERCY VANDORN (MD)
Entity type:Individual
Prefix:
First Name:PERCY
Middle Name:VANDORN
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 1:2880 DAUPHIN ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-2457
Mailing Address - Country:US
Mailing Address - Phone:251-473-1900
Mailing Address - Fax:251-470-8943
Practice Address - Street 1:610 PROVIDENCE PARK DR E
Practice Address - Street 2:BLDG 2, SUITE 203
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-4622
Practice Address - Country:US
Practice Address - Phone:251-633-2667
Practice Address - Fax:251-633-2179
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00006625207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000034516Medicaid
ALC71188OtherHEALTHSPRING PROVIDER #
AL4006497OtherAETNA PROVIDER #
AL51034516OtherBLUE CROSS PROVIDER #
AL51511130OtherBLUE CROSS AL PROV #
AL51521765OtherBLUE CROSS AL PROV #
ALC71188Medicare UPIN
ALC71188OtherHEALTHSPRING PROVIDER #
AL51511130OtherBLUE CROSS AL PROV #