Provider Demographics
NPI:1730187907
Name:BROCKMAN, TODD ALAN (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:ALAN
Last Name:BROCKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2000 S WHEELING AVE
Mailing Address - Street 2:403
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5639
Mailing Address - Country:US
Mailing Address - Phone:918-742-5513
Mailing Address - Fax:918-742-5570
Practice Address - Street 1:2000 S WHEELING AVE
Practice Address - Street 2:403
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5639
Practice Address - Country:US
Practice Address - Phone:918-742-5513
Practice Address - Fax:918-742-5570
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK15602207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKC94719Medicare UPIN