Provider Demographics
NPI:1932594736
Name:BROCKMAN, MOLLY MAGGARD (MD)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:MAGGARD
Last Name:BROCKMAN
Suffix:
Gender:F
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5196
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:115 HUSTON DR STE 1
Practice Address - Street 2:
Practice Address - City:SHEPHERDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40165-7250
Practice Address - Country:US
Practice Address - Phone:502-955-7311
Practice Address - Fax:502-891-8338
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY52490208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK310660OtherMEDICARE
KY52490OtherMEDICAL LICENSE
KY7100430860Medicaid