Provider Demographics
NPI:1386618809
Name:BROKAW, DAWN DIANE (MD)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:DIANE
Last Name:BROKAW
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:PO BOX 32950
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85064
Mailing Address - Country:US
Mailing Address - Phone:602-433-1822
Mailing Address - Fax:602-246-7060
Practice Address - Street 1:6553 E BAYWOOD AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206
Practice Address - Country:US
Practice Address - Phone:408-985-6200
Practice Address - Fax:480-985-2951
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ16107207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ106424Medicaid
AZ276461Medicaid
AZ276461Medicaid