Provider Demographics
NPI:1205955929
Name:BROCKINGTON, RACQUEL (DO)
Entity type:Individual
Prefix:
First Name:RACQUEL
Middle Name:
Last Name:BROCKINGTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 HAMLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-2206
Mailing Address - Country:US
Mailing Address - Phone:734-941-4991
Mailing Address - Fax:734-941-4919
Practice Address - Street 1:2151 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4161
Practice Address - Country:US
Practice Address - Phone:313-259-7990
Practice Address - Fax:313-259-7294
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013595207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1504Medicare PIN
MIMI1504034Medicare UPIN
MIMI1503034Medicare UPIN
MIMI1503Medicare PIN