Provider Demographics
NPI:1205833704
Name:MOORE, BROOKE CAROL (MD)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:CAROL
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1500 ROUTE 112 STE 101
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-8054
Mailing Address - Country:US
Mailing Address - Phone:631-751-3000
Mailing Address - Fax:631-509-6559
Practice Address - Street 1:2500 ROUTE 347
Practice Address - Street 2:BLDG 14A
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2554
Practice Address - Country:US
Practice Address - Phone:631-689-7800
Practice Address - Fax:631-689-3016
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY161222207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCS629OtherOXFORD
NY0C3233OtherHEALTHNET
NY01130890Medicaid
NM390001418OtherMEDICARE RAIL ROAD
NY01130890Medicaid
NY24F571Medicare ID - Type Unspecified
NY17018OtherVYTRA