Provider Demographics
NPI:1447306360
Name:BROCK, NANCY (OD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
Last Name:BROCK
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13180 SE 169TH AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-8727
Mailing Address - Country:US
Mailing Address - Phone:503-997-6763
Mailing Address - Fax:503-698-3398
Practice Address - Street 1:13180 SE 169TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086
Practice Address - Country:US
Practice Address - Phone:503-698-2375
Practice Address - Fax:503-698-3398
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2628ATI152WP0200X
OR2826ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
1508037607OtherORGANIZATION (GROUP) NPI
R0000WDBCWOtherMEDICARE GROUP PIN
R112792Medicare PIN