Individual
KEIRSUN CROCKETT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
790 CHURCH ST NE, MARIETTA, GA 30060-7282
(678) 239-0420
Mailing address
PO BOX 3157, INDIANAPOLIS, IN 46206-3157
(770) 405-2976
Taxonomy
Speciality
Code
Description
License number
State
2085N0700X
Neuroradiology Physician
077719
GA
2085R0202X
Diagnostic Radiology Physician
Primary
077719
GA
390200000X
Student in an Organized Health Care Education/Training Program
0116023629
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0116023629
VIRGINIA BOARD OF MEDICINE
VA
Enumeration date
07/08/2011
Last updated
02/21/2024
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