Provider Demographics
NPI:1316009079
Name:CROCKETT, KAREN ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:ELIZABETH
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 F AVENUE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607
Mailing Address - Country:US
Mailing Address - Phone:520-364-1429
Mailing Address - Fax:520-364-4261
Practice Address - Street 1:10566 N HWY 191
Practice Address - Street 2:
Practice Address - City:ELFRIDA
Practice Address - State:AZ
Practice Address - Zip Code:85610-9021
Practice Address - Country:US
Practice Address - Phone:520-642-2222
Practice Address - Fax:520-364-4261
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36374207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ169558Medicaid