Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 1890 | AZ |
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 1998 | IA |
NPI | 1104810001 |
---|---|
Provider Name | George Bradley Klock |
First Address | Des Moines, IA 50312-4104 |
Second Address | Des Moines, IA 50312-4104 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2005 |
Last Update Date | 23/05/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1104810001 | (05) | IA |
AZ0064860 | BCBS OF ARIZONA (01) | AZ |
E66786 | (02) |