Healthcare Provider Details

I. General information

NPI: 1760138648
Provider Name (Legal Business Name): BROOKLYN MEDICAL OFFICE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1681 44TH ST
BROOKLYN NY
11204-1049
US

IV. Provider business mailing address

1681 44TH ST
BROOKLYN NY
11204-1049
US

V. Phone/Fax

Practice location:
  • Phone: 845-662-2404
  • Fax:
Mailing address:
  • Phone: 845-662-2404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BLIMY JACOBS
Title or Position: AUTHRORIZED OFFICIAL
Credential:
Phone: 845-662-2404