Provider Demographics
NPI:1548477029
Name:BRODY, PAUL E (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:E
Last Name:BRODY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144-53 72 RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-2504
Mailing Address - Country:US
Mailing Address - Phone:917-650-5623
Mailing Address - Fax:
Practice Address - Street 1:73-05 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379
Practice Address - Country:US
Practice Address - Phone:718-894-5888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143755174400000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY53578OtherMEDICARE PTAN
NY97D14Q081Medicare PIN
NY53578OtherMEDICARE PTAN