Healthcare Provider Details

I. General information

NPI: 1710062849
Provider Name (Legal Business Name): GREG R BROCKBANK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 W FRANCIS
SPOKANE WA
99205
US

IV. Provider business mailing address

123 W FRANCIS
SPOKANE WA
99205
US

V. Phone/Fax

Practice location:
  • Phone: 509-483-9363
  • Fax: 509-483-0355
Mailing address:
  • Phone: 509-483-9363
  • Fax: 509-483-0355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO0000780
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: