Provider Demographics
NPI:1508861899
Name:BROCK, CYNTHIA DIANE (DO)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:DIANE
Last Name:BROCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:DIANE
Other - Last Name:MARTINSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:740-374-4500
Mailing Address - Fax:
Practice Address - Street 1:424 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:WV
Practice Address - Zip Code:26187-1249
Practice Address - Country:US
Practice Address - Phone:304-375-4656
Practice Address - Fax:304-375-2449
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007080207Q00000X
WV1549207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0048510000Medicaid
OH2118489Medicaid
OH000000684752OtherANTHEM
OH000000684752OtherANTHEM
OH000000684752OtherANTHEM
WV0048510000Medicaid
OH7426541Medicare PIN
WV4168781Medicare UPIN
WV0048510000Medicaid