Provider Demographics
NPI:1023018678
Name:BROCK, IRVIN PETE III (MD)
Entity Type:Individual
Prefix:DR
First Name:IRVIN
Middle Name:PETE
Last Name:BROCK
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10833 N SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILLS
Mailing Address - State:AZ
Mailing Address - Zip Code:85268-6182
Mailing Address - Country:US
Mailing Address - Phone:210-792-4192
Mailing Address - Fax:
Practice Address - Street 1:10833 N SKYLINE DR
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-6182
Practice Address - Country:US
Practice Address - Phone:210-792-4192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-26
Last Update Date:2016-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM15352084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F1150Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER
TXI42195Medicare UPIN