Provider Demographics
NPI:1790744555
Name:BROCKHOUSE, VICTORIA J (DO)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:J
Last Name:BROCKHOUSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2540 COLLEGE AND UNIVERSITY
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61790-2540
Mailing Address - Country:US
Mailing Address - Phone:309-438-2956
Mailing Address - Fax:309-438-3689
Practice Address - Street 1:702 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-2814
Practice Address - Country:US
Practice Address - Phone:309-567-1400
Practice Address - Fax:309-557-1461
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336.043935207Q00000X
IL036081580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
036081580OtherSTATE LIC
IL833120OtherMEDICARE GROUP
IL036081580Medicaid
IL080040113OtherRR MEDICARE GROUP PTAN
CA2264OtherRR MEDICARE GROUP PTAN
336043935OtherCONT SUBS
336043935OtherCONT SUBS
IL833120OtherMEDICARE GROUP