Provider Demographics
NPI:1598764672
Name:BROCKMAN, MARC EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:EDWARD
Last Name:BROCKMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1050 SE MONTEREY RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-4512
Mailing Address - Country:US
Mailing Address - Phone:772-283-2020
Mailing Address - Fax:772-220-9582
Practice Address - Street 1:1515 N FLAGLER DR
Practice Address - Street 2:SUITE 500
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-3428
Practice Address - Country:US
Practice Address - Phone:561-659-9700
Practice Address - Fax:561-659-7153
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPT3093152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620336150Medicaid
20823YOtherMEDICARE RETIRED RAILROAD
20823XOtherMEDICARE RETIRED RAILROAD
FL20823OtherBCBS OF FLORIDA
FL620336150Medicaid
20823XOtherMEDICARE RETIRED RAILROAD
FL20823XMedicare PIN