Basic Information
| Provider Information | |||||||||
| NPI: | 1548200777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROCKINGTON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | CARLOS | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 SAINT VINCENTS DR | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352051601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059302456 | ||||||||
| FaxNumber: | 2059302469 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 SAINT VINCENTS DR | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352051601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059302456 | ||||||||
| FaxNumber: | 2059302469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 11/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 17400 | AL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 051509855 | 05 | AL | MEDICAID | 130025436 | 01 | AL | RAILROAD MEDICARE | OTHER | 04970355 | 05 | MS | MEDICAID | 009938017 | 05 | AL | MEDICAID | 051509854 | 01 | AL | BLUE CROSS | OTHER | 051509855 | 01 | AL | BLUE CROSS | OTHER | 009901225 | 05 | AL | MEDICAID |