Healthcare Provider Details

I. General information

NPI: 1568857795
Provider Name (Legal Business Name): MARK BROCKMAN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2015
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 HUSTON DR STE 2
SHEPHERDSVILLE KY
40165-7250
US

IV. Provider business mailing address

PO BOX 776879
CHICAGO IL
60677-6879
US

V. Phone/Fax

Practice location:
  • Phone: 502-955-8979
  • Fax: 502-955-1205
Mailing address:
  • Phone: 502-272-5754
  • Fax: 502-272-5339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number51074
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: