Provider Demographics
NPI:1588640635
Name:BROOKLYN, JOHN ROSS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROSS
Last Name:BROOKLYN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 FLYNN AVE
Mailing Address - Street 2:SUITE 3J
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 SAN REMO DR
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6385
Practice Address - Country:US
Practice Address - Phone:802-488-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420008256207Q00000X
VT042-0008256207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT08V031OtherMVP
VT0009674Medicaid
1554OtherBLUE CROSS BLUE SHIELD
VT1554OtherVERMONT MANAGED CARE
385701OtherCIGNA
9674OtherTRICARE
VT0420008256OtherSTATE LICENSE
VT0009674Medicaid
VT0009674Medicaid