Healthcare Provider Details

I. General information

NPI: 1609885805
Provider Name (Legal Business Name): WADE DALE BROCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S SHACKLEFORD RD STE 220
LITTLE ROCK AR
72211-3847
US

IV. Provider business mailing address

900 S SHACKLEFORD RD STE 220
LITTLE ROCK AR
72211-3847
US

V. Phone/Fax

Practice location:
  • Phone: 501-223-2244
  • Fax: 501-223-2231
Mailing address:
  • Phone: 501-223-2244
  • Fax: 501-223-2231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberE2380
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: