Provider Demographics
NPI:1336216704
Name:SPROCK, MARJA J (MD)
Entity type:Individual
Prefix:MRS
First Name:MARJA
Middle Name:J
Last Name:SPROCK
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 1:101 EYSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3608
Mailing Address - Country:US
Mailing Address - Phone:321-806-3929
Mailing Address - Fax:321-806-3928
Practice Address - Street 1:101 EYSTER BLVD
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3608
Practice Address - Country:US
Practice Address - Phone:321-806-3929
Practice Address - Fax:321-806-3928
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI058523207V00000X
FLME100296207V00000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116624300Medicaid
MS058523OtherCOMMERCIAL-COMMERCIAL NUMBER
G46847Medicare UPIN