Provider Demographics
NPI:1417992900
Name:VAN BROCKLIN, MICHAEL D (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:VAN BROCKLIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1506
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-0409
Mailing Address - Country:US
Mailing Address - Phone:360-242-3008
Mailing Address - Fax:360-807-7687
Practice Address - Street 1:4330 MITCHELL WAY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-9175
Practice Address - Country:US
Practice Address - Phone:360-738-6860
Practice Address - Fax:360-738-6853
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001307152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1023190Medicaid
WA2027076Medicaid
AK00939832OtherRAIL ROAD MEDICARE
WA1010014Medicaid
WA410017358OtherRAIL ROAD MEDICARE
WA410014653OtherRAIL ROAD MEDICARE
WA410017366OtherRAIL ROAD MEDICARE
WAG319209219Medicare PIN
WAG000165107Medicare PIN
WAG000500160OtherMEDICARE
WAG000686624Medicare PIN
WA410017366OtherRAIL ROAD MEDICARE
WA410017358OtherRAIL ROAD MEDICARE
WA0399560001Medicare NSC
WAG000355056Medicare PIN