MEDICARE: JASON KELLY BROCKWAY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	K0427	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	752616977017	OTHER	TX	TRICARE CHAMPUS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	117311	OTHER	TX	SUPERIOR CHIPS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	752616977017	OTHER	TX	TRICARE
6	87581G	OTHER	TX	BCBS OF TEXAS
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	117311	OTHER	TX	CHIPS
9	5411635	OTHER	TX	AETNA

General Provider Information

NPI Number	:	1043283823
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON KELLY BROCKWAY MD

Provider Business Mailing Address
First Line	:	PO BOX 846098
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-6098
Country	:	US
Telephone Number	:	903-324-6450
Fax Number	:

Provider Business Practice Location Address
First Line	:	1718 S HENDERSON BLVD
Second Line	:
City	:	KILGORE
State	:	TX
Zip	:	75662-3566
Country	:	US
Telephone Number	:	903-983-2110
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2006
Last Update Date	:	04/10/2024

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Directions to “ JASON KELLY BROCKWAY MD” Practice Location

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