Provider Demographics
NPI:1245813393
Name:BROCK, CAMERON LYLE (MD)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:LYLE
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 1:4860 Y STREET
Mailing Address - Street 2:SUITE 3100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817
Mailing Address - Country:US
Mailing Address - Phone:916-703-2261
Mailing Address - Fax:
Practice Address - Street 1:4860 Y STREET
Practice Address - Street 2:SUITE 3100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817
Practice Address - Country:US
Practice Address - Phone:916-703-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBP10075317OtherBASIC POST GRADUATE TRAINING PERMIT (PIT) - TEXAS #