1114173937 NPI number — DR. BROOK L BROUHA MD/PHD

Table of content: DR. BROOK L BROUHA MD/PHD (NPI 1114173937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114173937 NPI number — DR. BROOK L BROUHA MD/PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUHA
Provider First Name:
BROOK
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD/PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114173937
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2285 CORPORATE CIR
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89074-7759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-360-2763
Provider Business Mailing Address Fax Number:
949-783-2880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7300 GIRARD AVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-5138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-750-2983
Provider Business Practice Location Address Fax Number:
858-750-2984
Provider Enumeration Date:
08/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207ND0900X , with the licence number:  A97902 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DL390Z . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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