Provider Demographics
NPI:1164472783
Name:BROCK, TARA LYNN (DPM)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:BROCK
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYNN
Other - Last Name:DECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:1500 ASSOCIATES DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2201
Mailing Address - Country:US
Mailing Address - Phone:563-584-4100
Mailing Address - Fax:563-584-4110
Practice Address - Street 1:1500 ASSOCIATES DR
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2201
Practice Address - Country:US
Practice Address - Phone:563-584-4420
Practice Address - Fax:563-584-4295
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000786213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0475020Medicaid
IAI17171Medicare ID - Type Unspecified
IA0475020Medicaid