1144434762 NPI number — DR. DANIEL SCOTT BROCKMAN D.O.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144434762 NPI number — DR. DANIEL SCOTT BROCKMAN D.O.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BROCKMAN

Provider First Name:

DANIEL

Provider Middle Name:

SCOTT

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

D.O.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1144434762

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/23/2013

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

12 HEMLOCK HILL RD

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ORCHARD PARK

Provider Business Mailing Address State Name:

NY

Provider Business Mailing Address Postal Code:

14127-3964

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

716-574-1551

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

462 GRIDER ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

BUFFALO

Provider Business Practice Location Address State Name:

NY

Provider Business Practice Location Address Postal Code:

14215-3021

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

716-574-1551

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

05/10/2007

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RC0200X , with the licence number:  249468 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 101924377 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
• Identifier: 111167 . This is a "GEISINGER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 212476 . This is a "UNISON-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 20067553 . This is a "AMERIHEALTH MERCY-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 1566797 . This is a "GATEWAY-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 1969203 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 897588 . This is a "CAREFIRST MD BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
• Identifier: 210805 . This is a "JOHNS HOPKINS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 2161248 . This is a "MAMSI-WMG" identifier . This identifiers is of the category "OTHER".
• Identifier: 50069804 . This is a "CAPITAL BLUE CROSS-WMG" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
• Identifier: 9203104 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".