Provider Demographics
NPI:1962561639
Name:EDGAR CROCKETT OD PS
Entity type:Organization
Organization Name:EDGAR CROCKETT OD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:P
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:206-439-7588
Mailing Address - Street 1:70 ANDOVER PARK W
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188
Mailing Address - Country:US
Mailing Address - Phone:206-439-7588
Mailing Address - Fax:206-241-6857
Practice Address - Street 1:70 ANDOVER PARK W
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188
Practice Address - Country:US
Practice Address - Phone:206-439-7588
Practice Address - Fax:206-241-6857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001214152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2021384Medicaid
WA2021384Medicaid
WAT02686Medicare UPIN