Basic Information
| Provider Information | |||||||||
| NPI: | 1205833704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | CAROL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 ROUTE 112 STE 101 | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117768054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317513000 | ||||||||
| FaxNumber: | 6315096559 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 ROUTE 347 | ||||||||
| Address2: | BLDG 14A | ||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117902554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316897800 | ||||||||
| FaxNumber: | 6316893016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 09/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 161222 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | CS629 | 01 | NY | OXFORD | OTHER | 0C3233 | 01 | NY | HEALTHNET | OTHER | 01130890 | 05 | NY | MEDICAID | 390001418 | 01 | NM | MEDICARE RAIL ROAD | OTHER |