Provider Demographics
NPI:1700378577
Name:HARNISCH, BROCK CARL
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:CARL
Last Name:HARNISCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9089 CLAIREMONT MESA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1225
Mailing Address - Country:US
Mailing Address - Phone:858-810-8628
Mailing Address - Fax:
Practice Address - Street 1:2230 E 12TH ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-1610
Practice Address - Country:US
Practice Address - Phone:312-375-4601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN14761092085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology