Healthcare Provider Details

I. General information

NPI: 1457359309
Provider Name (Legal Business Name): ROBERT D PROCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 SUPERIOR AVE
MUNSTER IN
46321-4037
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-934-4008
  • Fax: 219-934-4010
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number01059232A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: