Provider Demographics
NPI:1861490146
Name:BROCKMAN, EDWARD BRITT I (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:BRITT
Last Name:BROCKMAN
Suffix:I
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 1:519 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-3620
Mailing Address - Country:US
Mailing Address - Phone:812-948-0616
Mailing Address - Fax:812-949-3447
Practice Address - Street 1:519 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-3620
Practice Address - Country:US
Practice Address - Phone:812-948-0616
Practice Address - Fax:812-949-3447
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25140207W00000X
IN01039106A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000042632OtherANTHEM
KY64251408Medicaid
IN100076460Medicaid
KY1066494Medicaid
KY2434616000Medicaid
IN100076460Medicaid
KY1066494Medicaid
KY2434616000Medicaid
E16310Medicare UPIN
KY000000042632OtherANTHEM