Basic Information
| Provider Information | |||||||||
| NPI: | 1508183948 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROCK | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8614 SE 11TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972027012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039159093 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1615 DELAWARE ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605013601 | ||||||||
| FaxNumber: | 3605013648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2010 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD166695 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD60662849 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.