Provider Demographics
NPI:1699868851
Name:CROOKSTON, MICHAEL J I (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:CROOKSTON
Suffix:I
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 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5770 S 1500 W
Practice Address - Street 2:BLDG C
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-5216
Practice Address - Country:US
Practice Address - Phone:801-265-3049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT166921-12052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005767420Medicare PIN
UT006900205Medicare PIN