Provider Demographics
NPI:1760429153
Name:BOCK, S. ALLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:S.
Middle Name:ALLAN
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 970
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80038-0970
Mailing Address - Country:US
Mailing Address - Phone:303-280-2810
Mailing Address - Fax:303-280-2876
Practice Address - Street 1:3950 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-1104
Practice Address - Country:US
Practice Address - Phone:303-444-5991
Practice Address - Fax:303-443-5030
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18479174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01184795Medicaid
COC803574Medicare PIN
CO01184795Medicaid