Provider Demographics
NPI:1023179090
Name:SCHOCK, THEODORE K (DO)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:K
Last Name:SCHOCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:GA
Mailing Address - Zip Code:30628-0459
Mailing Address - Country:US
Mailing Address - Phone:706-788-3234
Mailing Address - Fax:706-788-2936
Practice Address - Street 1:63 W GIBSON ST
Practice Address - Street 2:
Practice Address - City:HARTWELL
Practice Address - State:GA
Practice Address - Zip Code:30643-1845
Practice Address - Country:US
Practice Address - Phone:706-376-6100
Practice Address - Fax:706-376-3394
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030882207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000373117EMedicaid
GA000373117EMedicaid
GA08BBSCKMedicare ID - Type Unspecified