Provider Demographics
NPI:1376649269
Name:BOCK, GERALD N (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:N
Last Name:BOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 ST MARKS PLAZA
Mailing Address - Street 2:C
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207
Mailing Address - Country:US
Mailing Address - Phone:209-956-4260
Mailing Address - Fax:209-475-6002
Practice Address - Street 1:1617 ST MARKS PLAZA
Practice Address - Street 2:C
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207
Practice Address - Country:US
Practice Address - Phone:209-956-4260
Practice Address - Fax:209-475-6002
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG24211207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G242110Medicaid
A42198Medicare UPIN
CA00G242110Medicare ID - Type Unspecified