Provider Demographics
NPI:1366645178
Name:SCHROCK, JONATHAN D (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:SCHROCK
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 1:2310 CALIFORNIA ROAD
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1228
Mailing Address - Country:US
Mailing Address - Phone:574-264-4163
Mailing Address - Fax:574-262-9650
Practice Address - Street 1:2310 CALIFORNIA ROAD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1228
Practice Address - Country:US
Practice Address - Phone:574-264-4163
Practice Address - Fax:574-262-9650
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063795A207L00000X, 207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200880560Medicaid
223420IIIMedicare PIN