Provider Demographics
NPI:1740395375
Name:BROCKMAN, MYRON D (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRON
Middle Name:D
Last Name:BROCKMAN
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:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-7241
Mailing Address - Fax:417-269-1459
Practice Address - Street 1:3800 S NATIONAL AVE
Practice Address - Street 2:#600
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5209
Practice Address - Country:US
Practice Address - Phone:417-269-1499
Practice Address - Fax:417-269-1459
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2A87207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201656642Medicaid
27635OtherBLUE CROSS
MO201656642Medicaid
P00375513Medicare PIN
A28116Medicare UPIN
962495144Medicare PIN
110220388Medicare PIN