Provider Demographics
NPI:1629050166
Name:BOCK, PETER A (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:BOCK
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 741331
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1331
Mailing Address - Country:US
Mailing Address - Phone:913-469-0503
Mailing Address - Fax:913-469-5267
Practice Address - Street 1:11164 S NOBLE DR
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-7572
Practice Address - Country:US
Practice Address - Phone:913-829-2440
Practice Address - Fax:913-338-1311
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-21026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100153680DMedicaid
B69325Medicare UPIN
KS100153680DMedicaid