Provider Demographics
NPI:1063655140
Name:BROOKS, GREGORY S (IDMT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:S
Last Name:BROOKS
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2355 FACULTY DRIVE SUITE 1N207
Mailing Address - Street 2:10TH AMDS
Mailing Address - City:USAFA
Mailing Address - State:CO
Mailing Address - Zip Code:80840
Mailing Address - Country:US
Mailing Address - Phone:719-333-5187
Mailing Address - Fax:
Practice Address - Street 1:2355 FACULTY DR SUITE 1N207
Practice Address - Street 2:10TH AMDS
Practice Address - City:USAFA
Practice Address - State:CO
Practice Address - Zip Code:80840
Practice Address - Country:US
Practice Address - Phone:719-333-5187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians