Provider Demographics
NPI:1962481655
Name:ANDERSON, BROCK (MD)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:ANDERSON
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 1:419 S WASHINGTON ST STE 102
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2951
Mailing Address - Country:US
Mailing Address - Phone:307-577-4220
Mailing Address - Fax:307-235-0931
Practice Address - Street 1:419 S WASHINGTON ST STE 102
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2951
Practice Address - Country:US
Practice Address - Phone:307-577-4220
Practice Address - Fax:307-235-0931
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93051208600000X, 2086S0127X
WY8753A208600000X, 2086S0127X, 2086S0102X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery