Basic Information
| Provider Information | |||||||||
| NPI: | 1023268315 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOKE NIDA, MD, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 S RENAISSANCE BLVD | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058444300 | ||||||||
| FaxNumber: | 4058444333 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 S RENAISSANCE BLVD | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058444300 | ||||||||
| FaxNumber: | 4058444333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2008 | ||||||||
| LastUpdateDate: | 09/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | NIDA | ||||||||
| AuthorizedOfficialFirstName: | BROOKE | ||||||||
| AuthorizedOfficialMiddleName: | ALLISON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 40588444311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.