Provider Demographics
NPI:1578593174
Name:BROCK, KENNETH J (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:BROCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 E STAN SCHLUETER LOOP STE 202
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-4554
Mailing Address - Country:US
Mailing Address - Phone:254-634-4244
Mailing Address - Fax:254-634-8809
Practice Address - Street 1:3901 E STAN SCHLUETER LOOP STE 202
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-4554
Practice Address - Country:US
Practice Address - Phone:254-634-4244
Practice Address - Fax:254-634-8809
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG29182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100282602Medicaid
TXC13779Medicare UPIN
TX100282602Medicaid