Healthcare Provider Details

I. General information

NPI: 1043211907
Provider Name (Legal Business Name): WILLIAM K BROKKEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 W PUEBLO ST STE 202
SANTA BARBARA CA
93105-6211
US

IV. Provider business mailing address

504 W PUEBLO ST STE 202
SANTA BARBARA CA
93105-6211
US

V. Phone/Fax

Practice location:
  • Phone: 805-682-6455
  • Fax: 805-687-1482
Mailing address:
  • Phone: 805-682-6455
  • Fax: 805-687-1482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberC33750
License Number StateCA

VIII. Authorized Official

Name: WILLIAM K BROKKEN
Title or Position: OWNER
Credential: MD
Phone: 805-682-6455