Provider Demographics
NPI:1336221555
Name:BROCKWAY, BRUCE ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALBERT
Last Name:BROCKWAY
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 1:3939 MEDICAL DR
Mailing Address - Street 2:110
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229
Mailing Address - Country:US
Mailing Address - Phone:210-692-1515
Mailing Address - Fax:210-692-0187
Practice Address - Street 1:3939 MEDICAL DR
Practice Address - Street 2:110
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-692-1515
Practice Address - Fax:210-692-0187
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1406207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00GT38OtherBCBS OF TX
00GT38Medicare ID - Type Unspecified
C13784Medicare UPIN