Provider Demographics
NPI:1073869350
Name:DEBENHAM, BROCK JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:JOHN
Last Name:DEBENHAM
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 1:515 W 59TH ST
Mailing Address - Street 2:APT 04E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1047
Mailing Address - Country:US
Mailing Address - Phone:718-663-1872
Mailing Address - Fax:
Practice Address - Street 1:515 W 59TH ST
Practice Address - Street 2:APT 04E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1047
Practice Address - Country:US
Practice Address - Phone:718-663-1872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP848732085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology