Provider Demographics
NPI:1184761777
Name:BROCKIE, ELISABETH SCHULTZ (DO)
Entity type:Individual
Prefix:
First Name:ELISABETH
Middle Name:SCHULTZ
Last Name:BROCKIE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 ALTA VISTA LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-2836
Mailing Address - Country:US
Mailing Address - Phone:214-350-2058
Mailing Address - Fax:
Practice Address - Street 1:1508 17TH ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-6300
Practice Address - Country:US
Practice Address - Phone:877-433-7284
Practice Address - Fax:877-433-7284
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9820207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH57972Medicare UPIN