Provider Demographics
NPI:1922061373
Name:BROCKSMITH, JAMES T (DO)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:T
Last Name:BROCKSMITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 E BROADWAY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7166
Mailing Address - Country:US
Mailing Address - Phone:573-875-6504
Mailing Address - Fax:573-875-7168
Practice Address - Street 1:1705 E BROADWAY
Practice Address - Street 2:SUITE 220
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7166
Practice Address - Country:US
Practice Address - Phone:573-875-6504
Practice Address - Fax:573-875-7168
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODOR3M91207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO242839900Medicaid
E23567Medicare UPIN
0957Medicare ID - Type Unspecified