Provider Demographics
NPI:1316174956
Name:CROCKETT, JOEL (MD)
Entity type:Individual
Prefix:DR
First Name:JOEL
Middle Name:
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5300 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2381
Mailing Address - Country:US
Mailing Address - Phone:937-433-7536
Mailing Address - Fax:937-433-9612
Practice Address - Street 1:20400 LAKE CHABOT RD STE 202
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5315
Practice Address - Country:US
Practice Address - Phone:510-881-7822
Practice Address - Fax:510-881-8552
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-22
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA150539207N00000X
MO2009016609207N00000X
OH35.122221207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology