Provider Demographics
NPI:1104826700
Name:ROCK, JONATHAN CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:CHARLES
Last Name:ROCK
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:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84402-0629
Mailing Address - Country:US
Mailing Address - Phone:580-536-9300
Mailing Address - Fax:580-539-7900
Practice Address - Street 1:950 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-4724
Practice Address - Country:US
Practice Address - Phone:435-734-9471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5571577-12052085R0202X
OK197852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100207220CMedicaid
OK243328301OtherINDIVIDUAL MEDICARE NUMBE