Provider Demographics
NPI:1578674206
Name:MOCLOCK, MICHAEL ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:MOCLOCK
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 1:610 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3702
Mailing Address - Country:US
Mailing Address - Phone:570-288-5441
Mailing Address - Fax:570-288-5842
Practice Address - Street 1:239 S MOUNTAIN BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:MOUNTAIN TOP
Practice Address - State:PA
Practice Address - Zip Code:18707-1911
Practice Address - Country:US
Practice Address - Phone:570-474-9300
Practice Address - Fax:570-474-0962
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD048533L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001467866Medicaid
PAF40432Medicare UPIN
PA149206Medicare ID - Type Unspecified