Provider Demographics
NPI:1770743460
Name:BROCKMEYER, REGAN R (DO)
Entity type:Individual
Prefix:
First Name:REGAN
Middle Name:R
Last Name:BROCKMEYER
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:PO BOX 5788
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5788
Mailing Address - Country:US
Mailing Address - Phone:303-202-1280
Mailing Address - Fax:303-202-1281
Practice Address - Street 1:340 PEAK ONE DR.
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443-0738
Practice Address - Country:US
Practice Address - Phone:970-668-8123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY258784207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ816333Medicaid
CO42371767Medicaid
WYPENDINGMedicaid
P00966243OtherRR MEDICARE
20326023101OtherPACIFICARE SECURE HORIZONS
UTPENDINGMedicaid
UTPENDINGMedicaid