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General NPI Number Information
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NPI Number | 1780952515
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Entity Type | Individual
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Provider Name | GERALD JAY BROOCK M.D.
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Gender | Male
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Dates
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Enumeration Date | 12/07/2011
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Last Update Date | 12/07/2011
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Provider Practice Location Address
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Address Line | 123 NW 12TH AVE APT. 1426
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City | PORTLAND
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State | OR
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Zip | 97209-4143
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Country | US
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Telephone | 757-561-6056
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Fax |
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Provider Business Mailing Address
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Address Line | 123 NW 12TH AVE APT. 1426
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City | PORTLAND
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State | OR
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Zip | 97209-4143
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Country | US
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Telephone | 757-561-6056
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | MD27913
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License Number State | OR
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