Provider Demographics
NPI:1710965363
Name:BROCK, DONALD (DO)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:
Last Name:BROCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 MOTOR PKWY STE 309
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-5124
Mailing Address - Country:US
Mailing Address - Phone:631-514-7600
Mailing Address - Fax:631-813-1472
Practice Address - Street 1:168 S HOWELL ST
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-2040
Practice Address - Country:US
Practice Address - Phone:517-437-4451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34009716207P00000X
KY04282207P00000X
MI5101011514207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF76193Medicare UPIN