Basic Information
| Provider Information | |||||||||
| NPI: | 1598733933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30309 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294170309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435549300 | ||||||||
| FaxNumber: | 8435568780 | ||||||||
| Practice Location | |||||||||
| Address1: | 6116 E WARREN AVE | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802225752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3035120888 | ||||||||
| FaxNumber: | 3035122288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 03/03/2008 | ||||||||
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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 | 207ZP0102X | 80222 | CO | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 01287234 | 05 | CO | MEDICAID | Z3386 | 05 | NM | MEDICAID | 641804 | 05 | AZ | MEDICAID | Z0238 | 05 | UT | MEDICAID |