Provider Demographics
NPI:1609885805
Name:BROCK, WADE DALE (MD)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:DALE
Last Name:BROCK
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 1:9800 BAPTIST HEALTH DR STE 500
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6243
Mailing Address - Country:US
Mailing Address - Phone:501-223-2244
Mailing Address - Fax:501-223-2231
Practice Address - Street 1:9800 BAPTIST HEALTH DR STE 500
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6243
Practice Address - Country:US
Practice Address - Phone:501-223-2244
Practice Address - Fax:501-223-2231
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2380207WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154129001Medicaid
ARDE6376OtherRAILROAD MEDICARE
H60643Medicare UPIN
AR5M843Medicare ID - Type Unspecified