Provider Demographics
NPI:1336140284
Name:BROKKEN, WILLIAM KENT (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:KENT
Last Name:BROKKEN
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 1:4433 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105
Mailing Address - Country:US
Mailing Address - Phone:805-886-8021
Mailing Address - Fax:805-687-1482
Practice Address - Street 1:4433 MEADOWLARK LN
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105
Practice Address - Country:US
Practice Address - Phone:805-886-8021
Practice Address - Fax:805-687-1482
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC33750207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D0584671OtherCLIA
1043211907OtherORGANIZATION NPI
WC33750AMedicare ID - Type Unspecified
CA05D0584671OtherCLIA
W17806Medicare PIN
1043211907OtherORGANIZATION NPI
DG8511Medicare PIN