Provider Demographics
NPI:1114447984
Name:BROOKOVER, AUSTIN TANNER (DO)
Entity Type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:TANNER
Last Name:BROOKOVER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5657 S MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-7712
Mailing Address - Country:US
Mailing Address - Phone:918-706-4922
Mailing Address - Fax:
Practice Address - Street 1:1400 E DOWNING ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3324
Practice Address - Country:US
Practice Address - Phone:918-456-0641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QS1000X, 390200000X
OK6370207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program