Healthcare Provider Details

I. General information

NPI: 1992037501
Provider Name (Legal Business Name): MARJA J SPROCK MD, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2010
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: 321-809-3923
Mailing address:
  • Phone: 321-806-3929
  • Fax: 321-806-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberG10000003345
License Number StateFL

VIII. Authorized Official

Name: TRISTAN KATTENBERG
Title or Position: OFFICE MANAGER
Credential:
Phone: 321-338-2726