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NPI Code Detail

MEDICARE: DR. ROGER D. BROCKBANK M.D.

MEDICARE: DR. ROGER D. BROCKBANK M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician4778712-1205UT

General Provider Information

NPI Number : 1669463626
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ROGER D. BROCKBANK M.D.
Provider Business Mailing Address
First Line : 275 W 200 N
Second Line :
City : LINDON
State : UT
Zip : 84042-5009
Country : US
Telephone Number : 801-796-1333
Fax Number : 801-756-1705
Provider Business Practice Location Address
First Line : 830 N 2000 W
Second Line :
City : PLEASANT GROVE
State : UT
Zip : 84062-4047
Country : US
Telephone Number : 801-756-3511
Fax Number : 801-443-1164
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/31/2005
Last Update Date : 05/01/2013

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