Provider Demographics
NPI:1295721207
Name:BROCK, JAY DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:DAVID
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:PO BOX 8023
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22404-8023
Mailing Address - Country:US
Mailing Address - Phone:540-371-4488
Mailing Address - Fax:
Practice Address - Street 1:4304 LAFAYETTE BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-4234
Practice Address - Country:US
Practice Address - Phone:540-891-5600
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB08200Medicare UPIN