Provider Demographics
NPI:1598255853
Name:BROCK, KATE ELENI (MD)
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:ELENI
Last Name:BROCK
Suffix:
Gender:F
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:PO BOX 245073
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85724-5073
Mailing Address - Country:US
Mailing Address - Phone:520-626-7944
Mailing Address - Fax:520-626-5652
Practice Address - Street 1:1501 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724-0001
Practice Address - Country:US
Practice Address - Phone:520-626-7944
Practice Address - Fax:520-626-5652
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-12
Last Update Date:2018-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR76642208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty