Healthcare Provider Details

I. General information

NPI: 1417028614
Provider Name (Legal Business Name): DEREK POWELL BROCK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 LAKESIDE DR
NORTH PALM BEACH FL
33408-3810
US

IV. Provider business mailing address

836 LAKESIDE DR
NORTH PALM BEACH FL
33408-3810
US

V. Phone/Fax

Practice location:
  • Phone: 561-622-4664
  • Fax:
Mailing address:
  • Phone: 561-622-4664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberME8906
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: