Provider Demographics
NPI:1194735316
Name:CROTEAU, DAVID I
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:I
Last Name:CROTEAU
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 1:5200 BABCOCK ST NE STE 101
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-4639
Mailing Address - Country:US
Mailing Address - Phone:321-728-8336
Mailing Address - Fax:
Practice Address - Street 1:208 MAIN ST
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-3404
Practice Address - Country:US
Practice Address - Phone:863-284-3930
Practice Address - Fax:863-284-3931
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME112289207Q00000X
MT53053207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT011001540Medicare PIN
MT1194735316Medicaid
MT000092236OtherBCBS
G90161Medicare UPIN