Provider Demographics
NPI:1922305853
Name:GAIL BROCKMAN M.D. A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GAIL BROCKMAN M.D. A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-277-7571
Mailing Address - Street 1:2080 CENTURY PARK E
Mailing Address - Street 2:SUITE 303
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2001
Mailing Address - Country:US
Mailing Address - Phone:310-277-7571
Mailing Address - Fax:310-277-1058
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:SUITE 303
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-277-7571
Practice Address - Fax:310-277-1058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-10
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG032969207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA45363Medicare UPIN