Provider Demographics
NPI:1619941754
Name:BROCKBANK, NEAL ROSS (DO)
Entity Type:Individual
Prefix:
First Name:NEAL
Middle Name:ROSS
Last Name:BROCKBANK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:OK
Mailing Address - Zip Code:74637-3023
Mailing Address - Country:US
Mailing Address - Phone:918-642-3100
Mailing Address - Fax:918-642-5415
Practice Address - Street 1:212 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:OK
Practice Address - Zip Code:74637-3023
Practice Address - Country:US
Practice Address - Phone:918-642-3100
Practice Address - Fax:918-642-5415
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2017-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5853207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100451050CMedicaid
KS05-30121OtherLICENSE #
OK200606010AMedicaid
OK200606010AMedicaid