Provider Demographics
NPI:1619199627
Name:BOCKEWITZ, BRANDON (MD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BOCKEWITZ
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 1:5100 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0001
Mailing Address - Country:US
Mailing Address - Phone:309-672-4809
Mailing Address - Fax:
Practice Address - Street 1:5401 N KNOXVILLE AVE STE 112
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5021
Practice Address - Country:US
Practice Address - Phone:309-693-2020
Practice Address - Fax:309-683-8850
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036121479207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036121479OtherLICENSE