Provider Demographics
NPI:1417210279
Name:BROCK, JONATHAN WILLIAM CERAL (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:WILLIAM CERAL
Last Name:BROCK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 CLEMSON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-4341
Mailing Address - Country:US
Mailing Address - Phone:803-788-6146
Mailing Address - Fax:803-462-0312
Practice Address - Street 1:2318A SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4716
Practice Address - Country:US
Practice Address - Phone:803-796-9200
Practice Address - Fax:803-462-0312
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD34729208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics