Healthcare Provider Details

I. General information

NPI: 1205955929
Provider Name (Legal Business Name): RACQUEL BROCKINGTON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 E JEFFERSON AVE
DETROIT MI
48207-4161
US

IV. Provider business mailing address

1914 LOURDES CT
LANSING MI
48910-0617
US

V. Phone/Fax

Practice location:
  • Phone: 313-259-7990
  • Fax: 313-259-7294
Mailing address:
  • Phone: 313-525-0365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101013595
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number5101013595
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: