Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 0420008256 | VT |
Y | 207RA0401X | Internist - Addiction Medicine | 042-0008256 | VT |
NPI | 1588640635 |
---|---|
Provider Name | Dr. John Ross Brooklyn |
First Address | Burlington, VT 05401-5429 |
Second Address | South Burlington, VT 05403-6385 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/12/2005 |
Last Update Date | 22/08/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0009674 | (05) | VT |
0420008256 | STATE LICENSE (01) | VT |
08V031 | MVP (01) | VT |
1554 | BLUE CROSS BLUE SHIELD (01) | |
1554 | VERMONT MANAGED CARE (01) | VT |
385701 | CIGNA (01) | |
9674 | TRICARE (01) | |
E41257 | (02) | VT |