Individual
CORNELIUS PAUL BROOKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2001 S WOODRUFF AVE, STE 12A, IDAHO FALLS, ID 83404-6374
(208) 522-8945
(208) 522-5374
Mailing address
2001 S WOODRUFF AVE, STE 12A, IDAHO FALLS, ID 83404-6374
(208) 522-8945
(208) 522-5374
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
5809M
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002685200
—
ID
01
—
58099
BLUE CROSS
—
01
—
77186
BLUE CROSS
ID
Enumeration date
01/27/2006
Last updated
07/05/2016
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