Provider Demographics
NPI:1548200777
Name:BROCKINGTON, JOHN CARLOS (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CARLOS
Last Name:BROCKINGTON
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 1:601 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-2231
Mailing Address - Country:US
Mailing Address - Phone:717-851-5503
Mailing Address - Fax:717-851-5507
Practice Address - Street 1:855 N WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7668
Practice Address - Country:US
Practice Address - Phone:920-303-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL174002084N0400X
WI31102084N0400X
PAMD4823082084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04970355Medicaid
WI100286787Medicaid
AL051509854OtherBLUE CROSS
AL130025436OtherRAILROAD MEDICARE
AL009901225Medicaid
AL009938017Medicaid
AL051509855OtherBLUE CROSS
AL051509855Medicaid