Provider Demographics
NPI:1356548002
Name:BROOME, DEAN CARL (MD,)
Entity type:Individual
Prefix:DR
First Name:DEAN
Middle Name:CARL
Last Name:BROOME
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 1:115 MAIN ST
Mailing Address - Street 2:PO BOX 271
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-0271
Mailing Address - Country:US
Mailing Address - Phone:912-449-1477
Mailing Address - Fax:
Practice Address - Street 1:115 MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516-0271
Practice Address - Country:US
Practice Address - Phone:912-449-1477
Practice Address - Fax:912-449-1479
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048604207R00000X, 208000000X, 2080A0000X, 2080P0205X, 209800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Not Answered2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Not Answered209800000XAllopathic & Osteopathic PhysiciansLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00886872AMedicaid
D38655Medicare UPIN