Provider Demographics
NPI:1023195807
Name:BROCK, WILLIAM BRADFORD (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:BRADFORD
Last Name:BROCK
Suffix:
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 1:1589 SPARTA ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MC MINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-1390
Mailing Address - Country:US
Mailing Address - Phone:931-815-3636
Mailing Address - Fax:931-815-3808
Practice Address - Street 1:1589 SPARTA ST
Practice Address - Street 2:SUITE 105
Practice Address - City:MC MINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-1390
Practice Address - Country:US
Practice Address - Phone:931-815-3636
Practice Address - Fax:931-815-3808
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD20114208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN193161OtherBLUE CROSS BLUE SHIELD
TN3050246Medicaid
TN6215739330002OtherCIGNA
TN3050246Medicaid
TN6215739330002OtherCIGNA