Provider Demographics
NPI:1629044920
Name:FLOCK, TRAVIS LEE (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:LEE
Last Name:FLOCK
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:PO BOX 116638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6638
Mailing Address - Country:US
Mailing Address - Phone:423-495-8659
Mailing Address - Fax:423-495-4970
Practice Address - Street 1:2525 DESALES AVENUE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-1161
Practice Address - Country:US
Practice Address - Phone:423-495-2620
Practice Address - Fax:423-495-2625
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29417207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3812437Medicare PIN
TNG52768Medicare UPIN