Provider Demographics
NPI:1982635553
Name:BROCK, HOWARD THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:THOMAS
Last Name:BROCK
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 1:914 BROAD ST
Mailing Address - Street 2:STE 2A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3817
Mailing Address - Country:US
Mailing Address - Phone:423-245-6101
Mailing Address - Fax:423-245-2396
Practice Address - Street 1:914 BROAD ST
Practice Address - Street 2:STE 2A
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3817
Practice Address - Country:US
Practice Address - Phone:423-245-6101
Practice Address - Fax:423-245-2396
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD11147208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA033503OtherANTHEM BCBS OF VIRGINIA
TN3173373Medicaid
5961032OtherAETNA
TN20009691OtherRAILROAD MEDICARE
VA7305605OtherVIRGINIA MEDICAID
TN0060917OtherBCBS TENNESSEE
VA7305605OtherVIRGINIA MEDICAID
TN3173373Medicaid