Basic Information
| Provider Information | |||||||||
| NPI: | 1114173937 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROUHA | ||||||||
| FirstName: | BROOK | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD/PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2285 CORPORATE CIR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890747759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023602763 | ||||||||
| FaxNumber: | 9497832880 | ||||||||
| Practice Location | |||||||||
| Address1: | 7300 GIRARD AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920375138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587502983 | ||||||||
| FaxNumber: | 8587502984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2008 | ||||||||
| LastUpdateDate: | 04/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | A97902 | CA | Y | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | DL390Z | 01 | CA | MEDICARE PTAN | OTHER |