Healthcare Provider Details

I. General information

NPI: 1730380502
Provider Name (Legal Business Name): LARRY DALE BROCK M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LARRY DALE BROCK MD

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 11/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 AIRPORT BLVD SUITE E
MOBILE AL
36608-3169
US

IV. Provider business mailing address

5809 FAIRFAX RD S
MOBILE AL
36608-2938
US

V. Phone/Fax

Practice location:
  • Phone: 251-342-0505
  • Fax: 251-342-0360
Mailing address:
  • Phone: 251-343-1598
  • Fax: 251-342-0360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number5347
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number5347
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: