Provider Demographics
NPI:1104193945
Name:MANOCCHIO, BROOKE LYNETTE (DO)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:LYNETTE
Last Name:MANOCCHIO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL
Mailing Address - Street 2:SUITE 550
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3794
Mailing Address - Country:US
Mailing Address - Phone:937-762-1305
Mailing Address - Fax:937-522-7513
Practice Address - Street 1:2115 LEITER RD
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-3659
Practice Address - Country:US
Practice Address - Phone:937-384-6800
Practice Address - Fax:937-384-6939
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.004216390200000X
OH34011470207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0112512Medicaid
OH0112512Medicaid