1093822561 NPI number — DAVID THOMAS BROCKBANK MD

Table of content: DAVID THOMAS BROCKBANK MD (NPI 1093822561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093822561 NPI number — DAVID THOMAS BROCKBANK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCKBANK
Provider First Name:
DAVID
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093822561
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1055 N 500 W
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84604-3305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-354-8225
Provider Business Mailing Address Fax Number:
801-418-0941

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6065 FASHION BLVD
Provider Second Line Business Practice Location Address:
STE 125
Provider Business Practice Location Address City Name:
MURRAY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84107-7381
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-261-0726
Provider Business Practice Location Address Fax Number:
801-262-2838
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  T2003013455 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 6540468-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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