Provider Demographics
NPI:1265164651
Name:MALATCHES, BROCK JOHN (MD)
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:JOHN
Last Name:MALATCHES
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27472 SCHOENHERR RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-6675
Mailing Address - Country:US
Mailing Address - Phone:586-751-8844
Mailing Address - Fax:586-751-8596
Practice Address - Street 1:27472 SCHOENHERR RD STE 100
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-6675
Practice Address - Country:US
Practice Address - Phone:586-751-8844
Practice Address - Fax:586-751-8596
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-26
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351049719390200000X
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program