Healthcare Provider Details

I. General information

NPI: 1184111346
Provider Name (Legal Business Name): AUSTIN BROKAMP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2018
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-9612
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberDR.0068617
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: