Provider Demographics
NPI:1215920707
Name:BROCKMOLE, DEAN M (MD)
Entity type:Individual
Prefix:
First Name:DEAN
Middle Name:M
Last Name:BROCKMOLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 UNION DEPOSIT RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-2910
Mailing Address - Country:US
Mailing Address - Phone:717-652-6105
Mailing Address - Fax:717-652-2165
Practice Address - Street 1:4518 UNION DEPOSIT RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17111-2921
Practice Address - Country:US
Practice Address - Phone:717-652-5840
Practice Address - Fax:717-652-8152
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037953E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011093380023Medicaid
PA300057799OtherRAILROAD MEDICARE
PA0011093380015Medicaid
PA0011093380020Medicaid
PA0011093380001Medicaid
PA0011093380022Medicaid
PA511118EF4Medicare PIN
PA511118NSUMedicare PIN
PA511118FJDMedicare PIN
PAB42315Medicare UPIN
PA0011093380020Medicaid
PA300057799OtherRAILROAD MEDICARE