Basic Information
| Provider Information | |||||||||
| NPI: | 1376538983 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROCKINGTON | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9135 | ||||||||
| Address2: | ATT:SHARON SILVA | ||||||||
| City: | BROOKLINE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024469135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009270002 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1153 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | JAMAICA PLAIN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021303446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175225800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 59672 | MA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 3061248 | 05 | MA | MEDICAID |