Provider Demographics
NPI:1710062849
Name:BROCKBANK, GREG R (DPM)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:R
Last Name:BROCKBANK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 W FRANCIS
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205
Mailing Address - Country:US
Mailing Address - Phone:509-483-9363
Mailing Address - Fax:509-483-0355
Practice Address - Street 1:123 W FRANCIS
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205
Practice Address - Country:US
Practice Address - Phone:509-483-9363
Practice Address - Fax:509-483-0355
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO0000780213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00326450OtherRAILRAOD MEDICARE
WA8430522Medicaid
WA200644OtherLABOR AND INDUSTRY
WAP00326450OtherRAILRAOD MEDICARE
V06323Medicare UPIN
WA200644OtherLABOR AND INDUSTRY
WA8430522Medicaid
WAG8855629Medicare PIN