Healthcare Provider Details

I. General information

NPI: 1750540308
Provider Name (Legal Business Name): BROOKE HEATHER BALCHAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2008
Last Update Date: 01/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E FORDHAM RD 6TH FLOOR
BRONX NY
10458-5039
US

IV. Provider business mailing address

400 E FORDHAM RD 6TH FLOOR
BRONX NY
10458-5039
US

V. Phone/Fax

Practice location:
  • Phone: 718-220-4176
  • Fax: 914-527-8273
Mailing address:
  • Phone: 718-220-4176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number254398
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: