Healthcare Provider Details

I. General information

NPI: 1376538983
Provider Name (Legal Business Name): GARY BROCKINGTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1153 CENTRE ST
JAMAICA PLAIN MA
02130-3446
US

IV. Provider business mailing address

PO BOX 9135 ATT:SHARON SILVA
BROOKLINE MA
02446-9135
US

V. Phone/Fax

Practice location:
  • Phone: 617-522-5800
  • Fax:
Mailing address:
  • Phone: 800-927-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number59672
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: