Provider Demographics
NPI:1104351592
Name:CROCKETT, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 E 3RD ST
Mailing Address - Street 2:ATT: VELVET GREEN, PROGRAM COORDINATOR EM RESIDENCY
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2147
Mailing Address - Country:US
Mailing Address - Phone:423-778-7673
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF UTAH SCHOOL OF MEDICINE 30 N 1900 E 1C026
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-2147
Practice Address - Country:US
Practice Address - Phone:801-581-2417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN59020207P00000X
390200000X
UT11680436-1205207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program