Basic Information
| Provider Information | |||||||||
| NPI: | 1588640635 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKLYN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ROSS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 FLYNN AVE | ||||||||
| Address2: | SUITE 3J | ||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054015429 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 75 SAN REMO DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054036385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024887350 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 08/22/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0420008256 | VT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207RA0401X | 042-0008256 | VT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 08V031 | 01 | VT | MVP | OTHER | 0009674 | 05 | VT | MEDICAID | 1554 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 1554 | 01 | VT | VERMONT MANAGED CARE | OTHER | 385701 | 01 | CIGNA | OTHER | 9674 | 01 | TRICARE | OTHER | 0420008256 | 01 | VT | STATE LICENSE | OTHER |