Provider Demographics
NPI:1891772356
Name:BROBECK, BRADLEY R (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:R
Last Name:BROBECK
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 1:1000 MAR WALT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6708
Mailing Address - Country:US
Mailing Address - Phone:850-315-7807
Mailing Address - Fax:850-863-7579
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-315-7807
Practice Address - Fax:850-863-7579
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2203532085R0202X
AL000273382085R0202X
FLME955802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ27261OtherBCBS MA
MA2060671Medicaid
MA469114OtherTUFTS HEALTH PLAN
AL106713Medicaid
AL106712Medicaid
AL108488Medicaid
FL275424000Medicaid
AL009939598Medicaid
AL108076Medicaid
051558196Medicare PIN
AL108076Medicaid
AL108488Medicaid
AL106713Medicaid
AL009939598Medicaid
051558194Medicare PIN