Healthcare Provider Details

I. General information

NPI: 1912991399
Provider Name (Legal Business Name): EVELYN S BROIKOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2066 HUDSON AVE
ROCHESTER NY
14617-4300
US

IV. Provider business mailing address

2250 TURK HILL RD
VICTOR NY
14564
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-2800
  • Fax: 585-922-2866
Mailing address:
  • Phone: 585-425-2820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number197121
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: