Provider Demographics
NPI:1740349695
Name:BROCKSTEIN, BRUCE EARL (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:EARL
Last Name:BROCKSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2650 RIDGE AVE
Mailing Address - Street 2:KELLOGG CANCER CENTER
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1718
Mailing Address - Country:US
Mailing Address - Phone:847-570-2112
Mailing Address - Fax:847-570-1041
Practice Address - Street 1:2650 RIDGE AVE
Practice Address - Street 2:KELLOGG CANCER CENTER
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-570-2112
Practice Address - Fax:847-570-1041
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036086058207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG23893Medicare UPIN