1730380502 NPI number — DR. LARRY DALE BROCK M.D

Table of content: DR. LARRY DALE BROCK M.D (NPI 1730380502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730380502 NPI number — DR. LARRY DALE BROCK M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROCK
Provider First Name:
LARRY
Provider Middle Name:
DALE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROCK
Provider Other First Name:
LARRY
Provider Other Middle Name:
DALE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1730380502
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5809 FAIRFAX RD S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOBILE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36608-2938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-343-1598
Provider Business Mailing Address Fax Number:
251-342-0360

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5901 AIRPORT BLVD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36608-3169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-342-0505
Provider Business Practice Location Address Fax Number:
251-342-0360
Provider Enumeration Date:
05/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2083P0901X , with the licence number:  5347 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Y00000X , with the licence number: 5347 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com