Provider Demographics
NPI:1427166537
Name:CROCKETT, BOYD D (MD)
Entity type:Individual
Prefix:DR
First Name:BOYD
Middle Name:D
Last Name:CROCKETT
Suffix:
Gender:M
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:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-9007
Mailing Address - Country:US
Mailing Address - Phone:417-875-3462
Mailing Address - Fax:
Practice Address - Street 1:3555 S NATIONAL AVE
Practice Address - Street 2:#302
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7310
Practice Address - Country:US
Practice Address - Phone:417-269-6868
Practice Address - Fax:417-269-6865
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001019052208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205373509Medicaid
146824OtherBLUE CROSS MO
963475151Medicare PIN
004012042Medicare PIN
146824OtherBLUE CROSS MO
MO205373509Medicaid
P00375945Medicare PIN