Provider Demographics
NPI:1043283823
Name:BROCKWAY, JASON KELLY (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:KELLY
Last Name:BROCKWAY
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:1718 S HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3566
Practice Address - Country:US
Practice Address - Phone:903-983-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0427207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX752616977017OtherTRICARE CHAMPUS
TX113244106Medicaid
TX117311OtherSUPERIOR CHIPS
TX081026902Medicaid
TX752616977017OtherTRICARE
TX87581GOtherBCBS OF TEXAS
TX113244103Medicaid
TX117311OtherCHIPS
TX5411635OtherAETNA
TX87581GOtherBCBS OF TEXAS
TX752616977017OtherTRICARE
G28484Medicare UPIN
TX113244103Medicaid