Provider Demographics
NPI:1306055868
Name:BOCK, JONATHON M (MD)
Entity type:Individual
Prefix:
First Name:JONATHON
Middle Name:M
Last Name:BOCK
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-8308
Mailing Address - Fax:414-805-7890
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8308
Practice Address - Fax:414-805-7890
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA34749207Y00000X
WI52867207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1306055868Medicaid
WI736011424Medicare PIN