Healthcare Provider Details

I. General information

NPI: 1396162749
Provider Name (Legal Business Name): BROCK D VANDERBUSH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2014
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6820 PARKDALE PL STE 212
INDIANAPOLIS IN
46254-6600
US

IV. Provider business mailing address

250 N SHADELAND AVE STE 200
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-216-2700
  • Fax: 317-216-2777
Mailing address:
  • Phone: 317-962-3834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number01082307A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number82220
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01082307A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: