Healthcare Provider Details

I. General information

NPI: 1649361312
Provider Name (Legal Business Name): PAUL DOUGLAS BRODY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 BALSAM DR
DIX HILLS NY
11746-7724
US

IV. Provider business mailing address

45 BALSAM DR
DIX HILLS NY
11746-7724
US

V. Phone/Fax

Practice location:
  • Phone: 631-424-8494
  • Fax: 631-920-8501
Mailing address:
  • Phone: 631-424-8494
  • Fax: 631-920-8501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number169787
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: