Healthcare Provider Details

I. General information

NPI: 1538861265
Provider Name (Legal Business Name): SAMUEL FORREST BROCK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 CENTRAL AVE
DOVER NH
03820-2526
US

IV. Provider business mailing address

333 BORTHWICK AVE STE 100
PORTSMOUTH NH
03801-4198
US

V. Phone/Fax

Practice location:
  • Phone: 603-740-2503
  • Fax:
Mailing address:
  • Phone: 603-559-4129
  • 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 Code207R00000X
TaxonomyInternal Medicine Physician
License Number39590
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: