Provider Demographics
NPI:1699887398
Name:BROCK, REGINA LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:REGINA
Middle Name:LYNN
Last Name:BROCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:REGINA
Other - Middle Name:LYNN
Other - Last Name:MCDANIELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:858 EASTERN BYP
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-2512
Mailing Address - Country:US
Mailing Address - Phone:859-626-0072
Mailing Address - Fax:859-626-9684
Practice Address - Street 1:858 EASTERN BYP
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2512
Practice Address - Country:US
Practice Address - Phone:859-626-0072
Practice Address - Fax:859-626-9684
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34004207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY34204OtherMED LIC (KY BOARD OF MED)
KY64050768Medicaid
BM6058247OtherDEPT OF JUSTICE - DEA
KY64050768Medicaid
KY34204OtherMED LIC (KY BOARD OF MED)
BM6058247OtherDEPT OF JUSTICE - DEA