Provider Demographics
NPI:1902025208
Name:BROCKWAY, JOHN M (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:BROCKWAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:KS
Mailing Address - Zip Code:66067-2218
Mailing Address - Country:US
Mailing Address - Phone:785-242-2386
Mailing Address - Fax:
Practice Address - Street 1:121 W 3RD ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:KS
Practice Address - Zip Code:66067-2218
Practice Address - Country:US
Practice Address - Phone:785-242-2386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-03361111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS22734-010OtherBCBS OF KANSAS CITY
KS22734-010OtherBCBS OF KANSAS CITY