Provider Demographics
NPI:1669885596
Name:BROKUS, KATHRYN (DO)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:BROKUS
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 1:35 WALKER ST
Mailing Address - Street 2:
Mailing Address - City:KITTERY
Mailing Address - State:ME
Mailing Address - Zip Code:03904-1727
Mailing Address - Country:US
Mailing Address - Phone:207-439-4430
Mailing Address - Fax:207-351-2216
Practice Address - Street 1:35 WALKER ST
Practice Address - Street 2:
Practice Address - City:KITTERY
Practice Address - State:ME
Practice Address - Zip Code:03904
Practice Address - Country:US
Practice Address - Phone:207-439-4430
Practice Address - Fax:207-439-0968
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO2726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1669885596Medicaid