Provider Demographics
NPI:1821128216
Name:BROCKETT, DAVID W (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:W
Last Name:BROCKETT
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8800 SE SUNNYSIDE RD.
Mailing Address - Street 2:STE. 300-N
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-5738
Mailing Address - Country:US
Mailing Address - Phone:281-286-2999
Mailing Address - Fax:512-607-4893
Practice Address - Street 1:3000 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1655
Practice Address - Country:US
Practice Address - Phone:541-673-1785
Practice Address - Fax:541-345-6315
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR237600000X
ORHAS-P-824882237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
2432417000OtherFEDERAL WORKERS COMP
OR212936Medicaid