Provider Demographics
NPI:1194793455
Name:BROOME, MARITA N (MD)
Entity type:Individual
Prefix:DR
First Name:MARITA
Middle Name:N
Last Name:BROOME
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARITA
Other - Middle Name:
Other - Last Name:NICKENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:655 WATKINS MILL RD
Practice Address - Street 2:KAISER PERMANENTE GAITHERSBURG MEDICAL CENTER
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3301
Practice Address - Country:US
Practice Address - Phone:240-632-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD19889207P00000X
MDD50332207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F76666Medicare UPIN