Healthcare Provider Details

I. General information

NPI: 1336216704
Provider Name (Legal Business Name): MARJA J SPROCK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 EYSTER BLVD
ROCKLEDGE FL
32955-3608
US

IV. Provider business mailing address

101 EYSTER BLVD
ROCKLEDGE FL
32955-3608
US

V. Phone/Fax

Practice location:
  • Phone: 321-806-3929
  • Fax: 321-806-3928
Mailing address:
  • Phone: 321-806-3929
  • Fax: 321-806-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number058523
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME100296
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberME100296
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: