Provider Demographics
NPI:1609001718
Name:BROCKETT, DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
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 1:1350 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-3454
Mailing Address - Country:US
Mailing Address - Phone:858-480-1044
Mailing Address - Fax:
Practice Address - Street 1:1350 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3454
Practice Address - Country:US
Practice Address - Phone:858-480-1044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA840772084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry