Healthcare Provider Details

I. General information

NPI: 1619941754
Provider Name (Legal Business Name): NEAL ROSS BROCKBANK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 08/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 N MAIN ST
FAIRFAX OK
74637-3023
US

IV. Provider business mailing address

212 N MAIN ST
FAIRFAX OK
74637-3023
US

V. Phone/Fax

Practice location:
  • Phone: 918-642-3100
  • Fax: 918-642-5415
Mailing address:
  • Phone: 918-642-3100
  • Fax: 918-642-5415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5853
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: