Provider Demographics
NPI:1396954699
Name:BROCKBANK, JUSTIN CLARK (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CLARK
Last Name:BROCKBANK
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 1:9235 N UNION BLVD STE 150 334
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7831
Mailing Address - Country:US
Mailing Address - Phone:719-638-1122
Mailing Address - Fax:719-638-1123
Practice Address - Street 1:6011 E WOODMEN RD STE 115
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-2603
Practice Address - Country:US
Practice Address - Phone:719-638-1122
Practice Address - Fax:719-638-1123
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00706382080S0012X
VA01012434932080P0214X
OH35.0973822080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Yes2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA018281V16Medicare PIN
VA1396954699Medicaid