Provider Demographics
NPI:1578548830
Name:BROCKER, BRIAN P (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:P
Last Name:BROCKER
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 1:1616 COVINGTON ST
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44510-1244
Mailing Address - Country:US
Mailing Address - Phone:330-747-9215
Mailing Address - Fax:330-747-9248
Practice Address - Street 1:1616 COVINGTON ST
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44510-1244
Practice Address - Country:US
Practice Address - Phone:330-747-9215
Practice Address - Fax:330-747-9248
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-066899207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000138342OtherANTHEM
OH0600127OtherUNITED HEALTHCARE
OH0976770Medicaid
OH4597438OtherAETNA
OH7405468OtherCIGNA
OH000000106032OtherUNISON
OH0600127OtherUNITED HEALTHCARE
OH0976770Medicaid