Healthcare Provider Details

I. General information

NPI: 1255018248
Provider Name (Legal Business Name): CAROL LYNN BROSGART MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2023
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3133 LEWISTON AVE
BERKELEY CA
94705-2716
US

IV. Provider business mailing address

3133 LEWISTON AVE
BERKELEY CA
94705-2716
US

V. Phone/Fax

Practice location:
  • Phone: 510-541-6200
  • Fax:
Mailing address:
  • Phone: 510-541-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberG-37121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: