Healthcare Provider Details

I. General information

NPI: 1760460463
Provider Name (Legal Business Name): DAVID C BROCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BERK RD
LEESPORT PA
19533-8705
US

IV. Provider business mailing address

404 OAK HILL LN
WYOMISSING PA
19610-3209
US

V. Phone/Fax

Practice location:
  • Phone: 610-376-4841
  • Fax: 610-376-4168
Mailing address:
  • Phone: 610-670-9255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD020471E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: