Provider Demographics
NPI:1265758973
Name:MILLET, BROCK W (MD)
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:W
Last Name:MILLET
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 1:790 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:COQUILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97423-1755
Mailing Address - Country:US
Mailing Address - Phone:541-396-7295
Mailing Address - Fax:541-396-7295
Practice Address - Street 1:790 E 5TH ST
Practice Address - Street 2:
Practice Address - City:COQUILLE
Practice Address - State:OR
Practice Address - Zip Code:97423-1755
Practice Address - Country:US
Practice Address - Phone:541-396-7295
Practice Address - Fax:541-396-7295
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD162167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR161133OtherGROUP MEDICAID NORTH BEND MEDICAL CENTER
ORR0000WFBTVOtherGROUP MEDICARE NORTH BEND MEDICAL CENTER
OR500656979Medicaid
ORP0125299OtherRAILROAD MEDICARE-OREGON
OR930635514OtherGROUP TAX FOR BILLING NORTH BEND MEDICAL CENTER
OR1407812365OtherGROUP NPI NORTH BEND MEDICAL CENTER
ORMD162167OtherMEDICAL LICENSE
ORMD162167OtherMEDICAL LICENSE