Provider Demographics
NPI:1568488435
Name:BROCK, MITCHELL VERNON (MD)
Entity type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:VERNON
Last Name:BROCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3025 SHRINE RD
Mailing Address - Street 2:SUTIE 190
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4788
Mailing Address - Country:US
Mailing Address - Phone:912-466-7250
Mailing Address - Fax:912-466-7253
Practice Address - Street 1:3025 SHRINE RD
Practice Address - Street 2:SUTIE 190
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4788
Practice Address - Country:US
Practice Address - Phone:912-466-7250
Practice Address - Fax:912-466-7253
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA051407207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000961958CMedicaid
GA000961958BMedicaid
GA16BBCTDMedicare ID - Type Unspecified