Provider Demographics
NPI:1740369974
Name:BRODY, SAMUEL ALAN (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:ALAN
Last Name:BRODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SAMUEL
Other - Middle Name:ALAN
Other - Last Name:BRODY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6915 YELLOWSTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:718-268-4500
Mailing Address - Fax:718-268-1336
Practice Address - Street 1:6915 YELLOWSTONE BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:718-268-4500
Practice Address - Fax:718-268-1336
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153180207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B87899Medicare UPIN
03569JMedicare ID - Type Unspecified