Provider Demographics
NPI:1093822561
Name:BROCKBANK, DAVID THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:THOMAS
Last Name:BROCKBANK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:6065 FASHION BLVD
Practice Address - Street 2:STE 125
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7381
Practice Address - Country:US
Practice Address - Phone:801-261-0726
Practice Address - Fax:801-262-2838
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOT2003013455207W00000X
UT6540468-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology