Brock, Jack A
Brock, Jack A is an individual health care provider with primary practice located at 4411 The 25 Way Ne Ste 150, Albuquerque NM 87109-5888. He recently has only one registered license in Allopathic & Osteopathic Physicians / Diagnostic Radiology, which is considered as his primary health care specialty. Brock, Jack A can be contacted via phone (505) 332-6900.Contact Information
Primary practice address
4411 The 25 Way Ne Ste 150
Albuquerque NM 87109-5888
Phone: (505) 332-6900
Fax: (505) 332-6921
Website:
Health care specialties
| Specialty | Code | License # | State |
|---|---|---|---|
| Allopathic & Osteopathic Physicians / Diagnostic Radiology | 2085R0202X | 77-139 | New Mexico |
Profile Details
| NPI number | 1851395610 |
|---|---|
| LBN Legal business name | Brock, Jack A |
| Credentials | Doctor of Medicine (MD) |
| Entity | Individual |
| Sole proprietor 1 | No |
| Enumeration date | Jun 9th, 2005 |
| Last updated | Oct 18th, 2007 - about 17 years ago |
1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.
Identifiers
| State | Type | Number | Issuer |
|---|---|---|---|
| All States | NPI | 1851395610 | NPPES |
| New Mexico | MEDICAID | L0634 | |
| New Mexico | MEDICAID | 52713 | |
| New Mexico | MEDICAID | 22467 | |
| New Mexico | MEDICAID | 45138 | |
| New Mexico | Other | 2258272 |
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