Healthcare Provider Details

I. General information

NPI: 1114173937
Provider Name (Legal Business Name): BROOK L BROUHA MD/PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 04/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 GIRARD AVE SUITE 104
LA JOLLA CA
92037-5138
US

IV. Provider business mailing address

2285 CORPORATE CIR STE 200
HENDERSON NV
89074-7759
US

V. Phone/Fax

Practice location:
  • Phone: 858-750-2983
  • Fax: 858-750-2984
Mailing address:
  • Phone: 702-360-2763
  • Fax: 949-783-2880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberA97902
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: