Provider Demographics
NPI:1477752988
Name:VEZINO, BROOKE (MD)
Entity Type:Individual
Prefix:DR
First Name:BROOKE
Middle Name:
Last Name:VEZINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:GUERNEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95446-1449
Mailing Address - Country:US
Mailing Address - Phone:707-869-5977
Mailing Address - Fax:707-869-5983
Practice Address - Street 1:6800 PALM AVE STE C
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4269
Practice Address - Country:US
Practice Address - Phone:707-824-9999
Practice Address - Fax:707-869-5983
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1538334065Medicaid
CA1538334065Medicaid