Provider Demographics
NPI:1114926912
Name:BROCK, RONALD LEROY (MD)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:LEROY
Last Name:BROCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:770-219-8440
Practice Address - Street 1:660 LANIER PARK DRIVE
Practice Address - Street 2:STE A
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2075
Practice Address - Country:US
Practice Address - Phone:770-535-0000
Practice Address - Fax:770-532-3911
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045044208800000X
GA45044208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00877632AMedicaid
GA00877632AMedicaid
GA34BDFJPMedicare ID - Type UnspecifiedMEDICARE NUMBER