Provider Demographics
NPI:1154323921
Name:KING, BROCK K (MD)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:K
Last Name:KING
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 1:525 WESTERN AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-4967
Mailing Address - Country:US
Mailing Address - Phone:501-327-4828
Mailing Address - Fax:501-327-6899
Practice Address - Street 1:525 WESTERN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-4967
Practice Address - Country:US
Practice Address - Phone:501-327-4828
Practice Address - Fax:501-327-6899
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2394208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR020048444OtherMEDICARE RAILROAD
AR1720143OtherUNITED HEALTH CARE
AR18487000000OtherQUALCHOICE
AR140135001Medicaid
AR18487000000OtherQUALCHOICE