Provider Demographics
NPI:1790496826
Name:GOONETILLEKE, BROOKE (OD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:GOONETILLEKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:278 MCCLOUD DR
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-5304
Mailing Address - Country:US
Mailing Address - Phone:201-390-0369
Mailing Address - Fax:
Practice Address - Street 1:348 MAIN ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-5803
Practice Address - Country:US
Practice Address - Phone:201-482-1216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009604-01152W00000X
NJ27OA00714900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist