Provider Demographics
NPI:1104323880
Name:BROCK, SAMANTHA GWEN (MD)
Entity type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:GWEN
Last Name:BROCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 W PERIMETER RD RM 3K43
Mailing Address - Street 2:
Mailing Address - City:JB ANDREWS
Mailing Address - State:MD
Mailing Address - Zip Code:20762-6602
Mailing Address - Country:US
Mailing Address - Phone:240-612-2464
Mailing Address - Fax:
Practice Address - Street 1:1060 W PERIMETER RD # R
Practice Address - Street 2:
Practice Address - City:JB ANDREWS
Practice Address - State:MD
Practice Address - Zip Code:20762-6602
Practice Address - Country:US
Practice Address - Phone:240-612-2464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
IN01083831A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program