Provider Demographics
NPI:1639241102
Name:BROCK, MICHAEL E (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:BROCK
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:2920 WINCHESTER AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-1962
Mailing Address - Country:US
Mailing Address - Phone:606-326-0649
Mailing Address - Fax:606-326-0650
Practice Address - Street 1:2920 WINCHESTER AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-1962
Practice Address - Country:US
Practice Address - Phone:606-326-0649
Practice Address - Fax:606-326-0650
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2023-03-07
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Provider Licenses
StateLicense IDTaxonomies
KY02828207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY02828OtherLICENSE NUMBER
KY2006030142OtherTAX ID #
KYBB8816398OtherDEA NUMBER
KYI06160Medicare UPIN