Provider Demographics
NPI:1730380502
Name:BROCK, LARRY DALE (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:DALE
Last Name:BROCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:LARRY
Other - Middle Name:DALE
Other - Last Name:BROCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:5809 FAIRFAX RD S
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-2938
Mailing Address - Country:US
Mailing Address - Phone:251-343-1598
Mailing Address - Fax:251-342-0360
Practice Address - Street 1:5901 AIRPORT BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3169
Practice Address - Country:US
Practice Address - Phone:251-342-0505
Practice Address - Fax:251-342-0360
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL53472083P0901X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology