Provider Demographics
NPI:1083657902
Name:BROOKS, ANDY THOMAS (RD)
Entity Type:Individual
Prefix:MR
First Name:ANDY
Middle Name:THOMAS
Last Name:BROOKS
Suffix:
Gender:M
Credentials:RD
Other - Prefix:MR
Other - First Name:ANDY
Other - Middle Name:THOMAS
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1989 OAK TREE CV STE B
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-1536
Mailing Address - Country:US
Mailing Address - Phone:901-488-0681
Mailing Address - Fax:
Practice Address - Street 1:1989 OAK TREE CV STE B
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-1536
Practice Address - Country:US
Practice Address - Phone:901-488-0681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD0908133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00974443AMedicaid
GAP71678Medicare UPIN
GA71BBBGWMedicare ID - Type UnspecifiedMEDICARE