Provider Demographics
NPI:1316049224
Name:BROCKMAN, TINA (MD)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BROCKMAN
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 1:1002 STEELHEAD CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-6473
Mailing Address - Country:US
Mailing Address - Phone:573-289-5344
Mailing Address - Fax:
Practice Address - Street 1:201 W BROADWAY
Practice Address - Street 2:SUITE 4A
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3842
Practice Address - Country:US
Practice Address - Phone:573-443-0937
Practice Address - Fax:573-875-7948
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2016-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008010706208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics