Provider Demographics
NPI:1043078611
Name:BROCK, PHILIP M (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:M
Last Name:BROCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 IRIS LN
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-7528
Mailing Address - Country:US
Mailing Address - Phone:931-456-2728
Mailing Address - Fax:931-456-5446
Practice Address - Street 1:15 IRIS LN
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-7528
Practice Address - Country:US
Practice Address - Phone:931-456-2728
Practice Address - Fax:931-456-5446
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program