Provider Demographics
NPI:1043211907
Name:WILLIAM K BROKKEN
Entity Type:Organization
Organization Name:WILLIAM K BROKKEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:BROKKEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-682-6455
Mailing Address - Street 1:504 W PUEBLO ST
Mailing Address - Street 2:STE 202
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-6211
Mailing Address - Country:US
Mailing Address - Phone:805-682-6455
Mailing Address - Fax:805-687-1482
Practice Address - Street 1:504 W PUEBLO ST
Practice Address - Street 2:STE 202
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-6211
Practice Address - Country:US
Practice Address - Phone:805-682-6455
Practice Address - Fax:805-687-1482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC33750207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0584671OtherCLIA
CA05D0584671OtherCLIA
DG8511Medicare PIN