Provider Demographics
NPI:1750540308
Name:BALCHAN, BROOKE HEATHER (DO)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:HEATHER
Last Name:BALCHAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E FORDHAM RD
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-5039
Mailing Address - Country:US
Mailing Address - Phone:718-220-4176
Mailing Address - Fax:
Practice Address - Street 1:400 E FORDHAM RD
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5039
Practice Address - Country:US
Practice Address - Phone:718-220-4176
Practice Address - Fax:914-527-8273
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-07
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY254398208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics