Provider Demographics
NPI:1720053952
Name:BROCK, JULIE C (OD)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:C
Last Name:BROCK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 COUNTY ROAD 135 E
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-9657
Mailing Address - Country:US
Mailing Address - Phone:662-538-9837
Mailing Address - Fax:
Practice Address - Street 1:107A TOWN CREEK DR
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866-7947
Practice Address - Country:US
Practice Address - Phone:662-869-1779
Practice Address - Fax:662-869-3776
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS661152W00000X
TN2280152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist