Provider Demographics
NPI:1679772297
Name:BROCK, TIMOTHY ZACHARY (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ZACHARY
Last Name:BROCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:148 BILL CARRUTH PKWY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-3754
Mailing Address - Country:US
Mailing Address - Phone:770-445-4915
Mailing Address - Fax:770-445-6876
Practice Address - Street 1:148 BILL CARRUTH PKWY
Practice Address - Street 2:SUITE 180
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3754
Practice Address - Country:US
Practice Address - Phone:770-445-4915
Practice Address - Fax:770-445-6876
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL30096208600000X
GA69551208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery