Healthcare Provider Details

I. General information

NPI: 1164166310
Provider Name (Legal Business Name): JOHN JOSEPH BROUGH III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 WISCONSIN AVE
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

8901 ROCKVILLE PIKE BLDG 193
BETHESDA MD
20889-0001
US

V. Phone/Fax

Practice location:
  • Phone: 301-319-8754
  • Fax:
Mailing address:
  • Phone: 301-319-8754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0116037351
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: