Provider Demographics
NPI:1679517171
Name:CROCKETT, SAMUEL E (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:E
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 1:2520 N ORANGE AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4638
Mailing Address - Country:US
Mailing Address - Phone:407-303-2801
Mailing Address - Fax:407-303-2805
Practice Address - Street 1:2520 N ORANGE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4638
Practice Address - Country:US
Practice Address - Phone:407-303-2801
Practice Address - Fax:407-303-2805
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME31027207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL48932OtherBCBS
FL48932WMedicare PIN
D55519Medicare UPIN