Provider Demographics
NPI:1609281153
Name:BROCKLAND, JOHN J (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:BROCKLAND
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 1:1 HOSPITAL DR
Mailing Address - Street 2:MCHANEY HALL 404, DCO75.00
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65212-1000
Mailing Address - Country:US
Mailing Address - Phone:573-884-2000
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:MCHANEY HALL 404, DCO75.00
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212
Practice Address - Country:US
Practice Address - Phone:573-884-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60826310207P00000X
MO2014018353208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine