Provider Demographics
NPI:1952577348
Name:PROCK, KRISTIN ANNE (DO)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:ANNE
Last Name:PROCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:M2 ANNEX
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-7112
Mailing Address - Country:US
Mailing Address - Phone:216-444-0933
Mailing Address - Fax:216-444-8530
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:M2 ANNEX
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-444-0933
Practice Address - Fax:216-444-8530
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.009916207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3109675Medicaid