Provider Demographics
NPI:1558349852
Name:ANDERSEN, BROCK ARBEN (MD)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:ARBEN
Last Name:ANDERSEN
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 1:2101 N WHITLEY DR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2132
Mailing Address - Country:US
Mailing Address - Phone:208-740-4981
Mailing Address - Fax:208-452-4499
Practice Address - Street 1:2101 N WHITLEY DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2132
Practice Address - Country:US
Practice Address - Phone:208-452-5999
Practice Address - Fax:208-452-4499
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11642207N00000X
CAA 93571207N00000X
IDM-11462207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology