Provider Demographics
NPI:1093930562
Name:BROOKS, KENNETH RYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RYAN
Last Name:BROOKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 NASA PKWY
Mailing Address - Street 2:SUITE 230
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058-3683
Mailing Address - Country:US
Mailing Address - Phone:713-363-9090
Mailing Address - Fax:
Practice Address - Street 1:2020 NASA PKWY
Practice Address - Street 2:SUITE 230
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-3683
Practice Address - Country:US
Practice Address - Phone:713-363-9090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088759207XX0005X, 207X00000X
TXN3515207XS0114X, 207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX206898301Medicaid
MI5209565Medicaid
TX206898304Medicaid
TX8FU628OtherBLUE CROSS BLUE SHIELD
TX8FU628OtherBLUE CROSS BLUE SHIELD
MI5209565Medicaid
TX8L20854Medicare PIN