Healthcare Provider Details

I. General information

NPI: 1083651004
Provider Name (Legal Business Name): CHRISTOPHER C BRODKIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 12/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1123 PACIFIC AVE
TACOMA WA
98402-4303
US

IV. Provider business mailing address

1123 PACIFIC AVE
TACOMA WA
98402-4303
US

V. Phone/Fax

Practice location:
  • Phone: 253-682-1710
  • Fax:
Mailing address:
  • Phone: 253-682-1710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036112196
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: