Provider Demographics
NPI:1932208345
Name:CROCKETT, CHARLES R (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3407
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47733-3407
Mailing Address - Country:US
Mailing Address - Phone:812-450-3405
Mailing Address - Fax:812-450-3099
Practice Address - Street 1:600 MARY ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47747-0001
Practice Address - Country:US
Practice Address - Phone:812-450-3405
Practice Address - Fax:812-450-3099
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036056A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64876568Medicaid
IN100337640Medicaid
INE39963Medicare UPIN
IN534980HMedicare PIN
IN100337640Medicaid
IN064694OtherHAMP PIN
IN195530OtherHEALTHLINK PIN
IN719157OtherFIRST HEALTH PIN
IN000000381070OtherBCBS - GATEWAY LOCATION