Provider Demographics
NPI:1952374779
Name:BROCK, GREGORY K (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:K
Last Name:BROCK
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 1:1436 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-1648
Mailing Address - Country:US
Mailing Address - Phone:812-232-7447
Mailing Address - Fax:812-232-6962
Practice Address - Street 1:1436 LOCUST ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1648
Practice Address - Country:US
Practice Address - Phone:812-232-7447
Practice Address - Fax:812-232-6962
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001784207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN080190613OtherRAILROAD MEDICARE
IN200179390Medicaid
INP00950465OtherRAILROAD
INP00950465OtherRAILROAD
INM400035879Medicare PIN
IN200179390Medicaid
INM400035881Medicare PIN