Provider Demographics
NPI:1871684753
Name:BROOKLYN FAMILY MEDICAL CARE
Entity Type:Organization
Organization Name:BROOKLYN FAMILY MEDICAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-783-3919
Mailing Address - Street 1:PO BOX 274
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-0274
Mailing Address - Country:US
Mailing Address - Phone:516-627-3354
Mailing Address - Fax:
Practice Address - Street 1:60 PLAZA ST E
Practice Address - Street 2:SUITE E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-5040
Practice Address - Country:US
Practice Address - Phone:718-783-3919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117032207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW6W541Medicare ID - Type Unspecified