Healthcare Provider Details

I. General information

NPI: 1770879843
Provider Name (Legal Business Name): BLAKE ROBERT OBROCK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 N TURQUOISE DR STE 200
FLAGSTAFF AZ
86001-2000
US

IV. Provider business mailing address

18444 N 25TH AVE STE 310
PHOENIX AZ
85023-1266
US

V. Phone/Fax

Practice location:
  • Phone: 928-774-7757
  • Fax: 928-774-7767
Mailing address:
  • Phone: 928-774-7757
  • Fax: 928-774-7767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberR3726
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number008371
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: