Provider Demographics
NPI:1477511749
Name:BROOK, BELLAMY (DO PC)
Entity Type:Individual
Prefix:DR
First Name:BELLAMY
Middle Name:
Last Name:BROOK
Suffix:
Gender:M
Credentials:DO PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 OLD COUNTRY RD STE 2
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2146
Mailing Address - Country:US
Mailing Address - Phone:631-405-5544
Mailing Address - Fax:800-627-1462
Practice Address - Street 1:300 OLD COUNTRY RD STE 2
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2146
Practice Address - Country:US
Practice Address - Phone:631-405-5544
Practice Address - Fax:800-627-1462
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215053-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY215053-1OtherSTATE PROFESSIONAL LICENS
NY11541228OtherCAQH ID
NYBB7036090OtherDEA
NYH34115Medicare UPIN
NY4P8822Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID