Provider Demographics
NPI:1508973397
Name:BROCKBANK, STEPHEN (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:BROCKBANK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2847 N 1050 E
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4033
Mailing Address - Country:US
Mailing Address - Phone:801-456-2020
Mailing Address - Fax:801-456-2021
Practice Address - Street 1:222 S MAIN ST
Practice Address - Street 2:SUITE 110
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-2174
Practice Address - Country:US
Practice Address - Phone:801-456-2020
Practice Address - Fax:801-456-2021
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5601485-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist