Provider Demographics
NPI:1689730996
Name:BROCK, PATRICIA CHARLENE LAURIE (DO)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:CHARLENE LAURIE
Last Name:BROCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-8618
Mailing Address - Country:US
Mailing Address - Phone:847-971-6855
Mailing Address - Fax:
Practice Address - Street 1:1420 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-8618
Practice Address - Country:US
Practice Address - Phone:847-971-6855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GO1546Medicare UPIN