Provider Demographics
NPI:1174784714
Name:BROCKE, MICHAEL ROBERT (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:BROCKE
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 1:808 CHALLENGER DR
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43469-9812
Mailing Address - Country:US
Mailing Address - Phone:419-849-3479
Mailing Address - Fax:
Practice Address - Street 1:808 CHALLENGER DR
Practice Address - Street 2:
Practice Address - City:WOODVILLE
Practice Address - State:OH
Practice Address - Zip Code:43469-9812
Practice Address - Country:US
Practice Address - Phone:419-849-3479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.031731207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology