Provider Demographics
NPI:1366419343
Name:BROCKETT, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BROCKETT
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 1:108 TECUMSEH DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-5435
Mailing Address - Country:US
Mailing Address - Phone:740-374-4273
Mailing Address - Fax:
Practice Address - Street 1:300 E 8TH ST STE 120
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-3379
Practice Address - Country:US
Practice Address - Phone:740-374-4273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043094207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0056463000Medicaid
OH0433150Medicaid
OH0433150Medicaid
WV0056463000Medicaid
OHP00602268OtherRRMCR
OH000000562035OtherANTHEM
WV0056463000Medicaid