Provider Demographics
NPI:1205991031
Name:BOCK, RANDALL (MD)
Entity type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:
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 1:1660 SOLDIERS FIELD RD # 1021
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-1108
Mailing Address - Country:US
Mailing Address - Phone:617-901-4847
Mailing Address - Fax:
Practice Address - Street 1:465 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORTH ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02760-2159
Practice Address - Country:US
Practice Address - Phone:508-316-0725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA51810208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6199682Medicaid
MA6199682Medicaid
MAB87158Medicare UPIN