Provider Demographics
NPI:1124104112
Name:BROKSCHMIDT, CAROL LYNN (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNN
Last Name:BROKSCHMIDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9522 E MINTON ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-2538
Mailing Address - Country:US
Mailing Address - Phone:480-354-8766
Mailing Address - Fax:
Practice Address - Street 1:CORNER OF RT. N12 AND N7
Practice Address - Street 2:FORT DEFIANCE PHS HOSPITAL
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ19747207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ19747OtherLICENSE
AZ893356OtherAHCCCS
NM52424553Medicaid