Provider Demographics
NPI:1285605949
Name:CROCCO, MARY JULIE (CNM)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JULIE
Last Name:CROCCO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4422 3RD AVE
Mailing Address - Street 2:DEPARTMENT OF OBSTETRICS & GYNECOLOGY
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-2545
Mailing Address - Country:US
Mailing Address - Phone:718-960-9415
Mailing Address - Fax:
Practice Address - Street 1:4422 3RD AVE
Practice Address - Street 2:DEPARTMENT OF OBSTETRICS & GYNECOLOGY
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2545
Practice Address - Country:US
Practice Address - Phone:718-960-9415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000124367A00000X
NY000158367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0508566OtherCIGNA
CTOV6320OtherHEALTHNET
CTP1904733OtherOXFORD
CA00195491003OtherUHC
CT004180452Medicaid
CT000124OtherCONNECTICARE
CT004180452-00OtherANTHEM