Healthcare Provider Details
I. General information
NPI: 1063732055
Provider Name (Legal Business Name): BROOKTIETE ASSERES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 06/02/2010
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:
III. Provider practice location address
3569 WILLOW GREEN DR
APEX NC
27502-2507
US
IV. Provider business mailing address
3569 WILLOW GREEN DR
APEX NC
27502-2507
US
V. Phone/Fax
- Phone: 240-338-1418
- Fax:
- Phone: 240-338-1418
- Fax:
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 208000000X |
| Taxonomy | Pediatrics Physician |
| License Number | D97797 |
| License Number State | MD |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 208D00000X |
| Taxonomy | General Practice Physician |
| License Number | 2013-01617 |
| License Number State | NC |
| # 3 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 208000000X |
| Taxonomy | Pediatrics Physician |
| License Number | 2013-01617 |
| License Number State | NC |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 1513788 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | WELLPATH |
| # 2 | |
| Identifier | 247602 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | MEDCOST, LLC |
| # 3 | |
| Identifier | 3652537 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | UNITED HEALTHCARE |
| # 4 | |
| Identifier | 7520999 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | AETNA |
| # 5 | |
| Identifier | 1063732055 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | DOCTORS DIRECT |
| # 6 | |
| Identifier | 1063732055 |
| Identifier Type | MEDICAID |
| Identifier State | NC |
| Identifier Issuer | |
| # 7 | |
| Identifier | 1063732055 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | HEALTHNET FEDERAL SERVICES |
| # 8 | |
| Identifier | 1063732055 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | HUMANA |
| # 9 | |
| Identifier | 13305729 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | PHCS-MULTIPLAN |
| # 10 | |
| Identifier | 1513788 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | COVENTRY OF THE CAROLINAS |
| # 11 | |
| Identifier | 1806P |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | BCBS OF NC |
| # 12 | |
| Identifier | 9225005 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | CIGNA-GREATWEST |
| # 13 | |
| Identifier | FH1101395 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | FIRST CAROLINA CARE |
| # 14 | |
| Identifier | 1063732055 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | HEALTHSMART |
| # 15 | |
| Identifier | 4468100 |
| Identifier Type | OTHER |
| Identifier State | NC |
| Identifier Issuer | COVENTRY NATIONAL - COVENTRY PPO |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
