Provider Demographics
NPI:1417956970
Name:BROCK, MITZI C (MD)
Entity type:Individual
Prefix:DR
First Name:MITZI
Middle Name:C
Last Name:BROCK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1627
Mailing Address - Country:US
Mailing Address - Phone:904-262-5333
Mailing Address - Fax:904-262-5337
Practice Address - Street 1:11945 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-1613
Practice Address - Country:US
Practice Address - Phone:904-262-5333
Practice Address - Fax:904-262-5337
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78839207V00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263632800OtherMEDIPASS
FL17343OtherBCBS
FL263632800Medicaid
FL285303OtherAVMED
FLME78839OtherMEDICAL LICENSE
FLP00187785OtherMEDICARE RAILROAD
FLME78839OtherMEDICAL LICENSE
FLME78839OtherMEDICAL LICENSE
FLH66962Medicare UPIN