Provider Demographics
NPI:1447410394
Name:CROCKER, JUSTIN ADAMS
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ADAMS
Last Name:CROCKER
Suffix:
Gender:M
Credentials:
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 63362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3362
Mailing Address - Country:US
Mailing Address - Phone:919-684-8111
Mailing Address - Fax:
Practice Address - Street 1:3480 WAKE FOREST RD
Practice Address - Street 2:SUITE 500
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7376
Practice Address - Country:US
Practice Address - Phone:919-862-5075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00470207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology