Healthcare Provider Details

I. General information

NPI: 1619933942
Provider Name (Legal Business Name): BROCK ADAM MERRITT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 N 19TH AVE
PHOENIX AZ
85021-7980
US

IV. Provider business mailing address

727 E BETHANY HOME RD STE B112
PHOENIX AZ
85014-2151
US

V. Phone/Fax

Practice location:
  • Phone: 602-973-3100
  • Fax: 602-973-0978
Mailing address:
  • Phone: 602-973-3100
  • Fax: 602-973-0978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4072
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: