Provider Demographics
NPI:1780664052
Name:BROCKWAY, DAVID P (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:BROCKWAY
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 1:6440 NICOLLET AVE SO
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1697
Mailing Address - Country:US
Mailing Address - Phone:612-861-1622
Mailing Address - Fax:612-861-2307
Practice Address - Street 1:6440 NICOLLET AVE SO
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1697
Practice Address - Country:US
Practice Address - Phone:612-861-1622
Practice Address - Fax:612-861-2307
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN26826207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN141265500Medicaid
1267420001Medicare NSC
A94729Medicare UPIN
MN141265500Medicaid