Provider Demographics
NPI:1538155890
Name:DEBROCK, BART J (MD)
Entity type:Individual
Prefix:
First Name:BART
Middle Name:J
Last Name:DEBROCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 N 2ND ST STE 200
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1353
Mailing Address - Country:US
Mailing Address - Phone:812-882-4320
Mailing Address - Fax:812-882-2706
Practice Address - Street 1:328 N 2ND ST STE 200
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1353
Practice Address - Country:US
Practice Address - Phone:812-882-4320
Practice Address - Fax:812-882-2706
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044481208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000086989OtherANTHEM
IN200076370Medicaid
G20557Medicare UPIN
IN200076370Medicaid
IN200076370AMedicaid