Provider Demographics
NPI:1164927307
Name:BROCKER, BENJAMIN ROBERT
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ROBERT
Last Name:BROCKER
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 1:8423 MARKET ST STE 101
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6778
Mailing Address - Country:US
Mailing Address - Phone:330-729-8700
Mailing Address - Fax:330-729-8701
Practice Address - Street 1:7341 EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5900
Practice Address - Country:US
Practice Address - Phone:330-726-1138
Practice Address - Fax:330-726-6128
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.015108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine