Healthcare Provider Details

I. General information

NPI: 1003205170
Provider Name (Legal Business Name): BROCK AARON MARTIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S JACKSON ST
LOUISVILLE KY
40202-1622
US

IV. Provider business mailing address

300 PASTEUR DR # L235
STANFORD CA
94305-2200
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-1816
  • Fax:
Mailing address:
  • Phone: 650-723-5252
  • Fax: 650-725-6902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number122382
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number54794
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: