Provider Demographics
NPI:1205374683
Name:BROOKS, RYAN (DO)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:BROOKS
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 1:4243 NW FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:JENSEN BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34957-3600
Mailing Address - Country:US
Mailing Address - Phone:800-735-1178
Mailing Address - Fax:772-223-6354
Practice Address - Street 1:4243 NW FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-3600
Practice Address - Country:US
Practice Address - Phone:800-735-1178
Practice Address - Fax:772-223-6354
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS16866208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115120600Medicaid