Provider Demographics
NPI:1104810795
Name:CROTTY, JOHN WILLIAM (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIAM
Last Name:CROTTY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 ALDEN DR
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NE
Mailing Address - Zip Code:68305-3021
Mailing Address - Country:US
Mailing Address - Phone:402-274-3218
Mailing Address - Fax:402-274-4538
Practice Address - Street 1:922 ALDEN DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NE
Practice Address - Zip Code:68305-3021
Practice Address - Country:US
Practice Address - Phone:402-274-3218
Practice Address - Fax:402-274-4538
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE815152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
47-0610838OtherFEDERAL TAX I.D.
NE815OtherOPTOMETRY LICENSE
MC0048745OtherCONTROLLED SUBSTANCE REGI
47-0610838OtherFEDERAL TAX I.D.
NE815OtherOPTOMETRY LICENSE