Provider Demographics
NPI:1083153472
Name:BROWN-SIMPSON, DORETHA CLARA (ED D)
Entity Type:Individual
Prefix:DR
First Name:DORETHA
Middle Name:CLARA
Last Name:BROWN-SIMPSON
Suffix:
Gender:F
Credentials:ED D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-24 144 AVENUE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-3501
Mailing Address - Country:US
Mailing Address - Phone:917-854-3290
Mailing Address - Fax:718-341-0005
Practice Address - Street 1:22424 144TH AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-3501
Practice Address - Country:US
Practice Address - Phone:917-854-3290
Practice Address - Fax:718-341-0005
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195920021174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1016Medicaid