Healthcare Provider Details

I. General information

NPI: 1164472783
Provider Name (Legal Business Name): TARA LYNN BROCK D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA LYNN DECKER D.P.M.

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 ASSOCIATES DR
DUBUQUE IA
52002-2201
US

IV. Provider business mailing address

1500 ASSOCIATES DR
DUBUQUE IA
52002-2201
US

V. Phone/Fax

Practice location:
  • Phone: 563-584-4420
  • Fax: 563-584-4295
Mailing address:
  • Phone: 563-584-4100
  • Fax: 563-584-4110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000786
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: