Provider Demographics
NPI:1053312967
Name:BROCKMAN, ROBERT HARRY (DC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:HARRY
Last Name:BROCKMAN
Suffix:
Gender:M
Credentials:DC
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 352
Mailing Address - Street 2:
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-0352
Mailing Address - Country:US
Mailing Address - Phone:319-372-3800
Mailing Address - Fax:
Practice Address - Street 1:2311 AVENUE L STE 3
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-4031
Practice Address - Country:US
Practice Address - Phone:319-372-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04987111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1218768Medicaid
IA10206OtherBCBS
IA1218768Medicaid