Healthcare Provider Details

I. General information

NPI: 1386905073
Provider Name (Legal Business Name): BROOKE MARIE ROEBUCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 BROADWAY
NEWPORT RI
02840-2747
US

IV. Provider business mailing address

164 BROADWAY
NEWPORT RI
02840-2747
US

V. Phone/Fax

Practice location:
  • Phone: 401-267-9928
  • Fax: 401-753-7519
Mailing address:
  • Phone: 401-267-9928
  • Fax: 401-753-7519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number29288
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD16497
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: