Provider Demographics
NPI:1861856080
Name:BROCK, KENNETH M (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:M
Last Name:BROCK
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 1:215 8TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-2093
Mailing Address - Country:US
Mailing Address - Phone:631-942-9869
Mailing Address - Fax:
Practice Address - Street 1:19 THE PINES
Practice Address - Street 2:
Practice Address - City:OLD WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11568-1126
Practice Address - Country:US
Practice Address - Phone:516-633-1436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3305432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology