Healthcare Provider Details

I. General information

NPI: 1598764672
Provider Name (Legal Business Name): MARC EDWARD BROCKMAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 N FLAGLER DR SUITE 500
WEST PALM BEACH FL
33401-3428
US

IV. Provider business mailing address

1050 SE MONTEREY RD SUITE 104
STUART FL
34994-4512
US

V. Phone/Fax

Practice location:
  • Phone: 561-659-9700
  • Fax: 561-659-7153
Mailing address:
  • Phone: 772-283-2020
  • Fax: 772-220-9582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT3093
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: