Provider Demographics
NPI:1699771675
Name:BOCK, JOHN EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:BOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 RIVERWOOD CT
Mailing Address - Street 2:STE 104
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2824
Mailing Address - Country:US
Mailing Address - Phone:936-953-9119
Mailing Address - Fax:936-539-1183
Practice Address - Street 1:800 RIVERWOOD CT
Practice Address - Street 2:STE 104
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2824
Practice Address - Country:US
Practice Address - Phone:936-953-9119
Practice Address - Fax:936-539-1183
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3979174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100079601Medicaid
TXC13566Medicare UPIN
TX00SR12Medicare PIN