Healthcare Provider Details

I. General information

NPI: 1639033129
Provider Name (Legal Business Name): DILLONBROCKMAN ISAAC BROCKMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 SOUTH GREEN STREET PO BOX 81
FOUNTAIN CITY IN
47341
US

IV. Provider business mailing address

205 SOUTH GREEN STREET PO BOX 81
FOUNTAIN CITY IN
47341
US

V. Phone/Fax

Practice location:
  • Phone: 765-259-1403
  • Fax:
Mailing address:
  • Phone: 765-259-1403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: