Provider Demographics
NPI:1871927269
Name:BROCK, JONATHAN RUSSELL (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:RUSSELL
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 1:1062 FORSYTH ST STE 1B
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-8638
Mailing Address - Country:US
Mailing Address - Phone:478-741-1208
Mailing Address - Fax:478-741-1557
Practice Address - Street 1:1062 FORSYTH ST STE 1B
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-8638
Practice Address - Country:US
Practice Address - Phone:478-741-1208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-00009207R00000X
390200000X
GA102044207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program