Provider Demographics
NPI:1336600170
Name:CLARK, BROCK STEPHEN (DO)
Entity Type:Individual
Prefix:DR
First Name:BROCK
Middle Name:STEPHEN
Last Name:CLARK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 E 37TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-1116
Mailing Address - Country:US
Mailing Address - Phone:352-361-1551
Mailing Address - Fax:
Practice Address - Street 1:2001 VAIL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1248
Practice Address - Country:US
Practice Address - Phone:704-304-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2022-01455207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program