Provider Demographics
NPI:1104967900
Name:NIDA, BROOKE A (MD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:NIDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:405-844-4300
Mailing Address - Fax:405-844-4333
Practice Address - Street 1:1700 S RENAISSANCE BLVD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-844-4300
Practice Address - Fax:405-844-4333
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2017-07-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK24592208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200194500AMedicaid
OK200194500BMedicaid
OK200194500BMedicaid