Provider Demographics
NPI:1104810001
Name:KLOCK, GEORGE BRADLEY (DO)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:BRADLEY
Last Name:KLOCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:G
Other - Middle Name:BRADLEY
Other - Last Name:KLOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO PC
Mailing Address - Street 1:3200 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-4104
Mailing Address - Country:US
Mailing Address - Phone:515-271-1722
Mailing Address - Fax:515-271-1697
Practice Address - Street 1:3200 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-4104
Practice Address - Country:US
Practice Address - Phone:515-271-1722
Practice Address - Fax:515-271-1697
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1890204D00000X
IA1998204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0064860OtherBCBS OF ARIZONA
IA1104810001Medicaid
AZD01890Medicare ID - Type Unspecified
IA1104810001Medicaid
IAI20216Medicare PIN