Provider Demographics
NPI:1205834306
Name:MARTIN, BROOKS (MD)
Entity Type:Individual
Prefix:DR
First Name:BROOKS
Middle Name:
Last Name:MARTIN
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 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:1090 3RD ST
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3485
Practice Address - Country:US
Practice Address - Phone:530-543-5660
Practice Address - Fax:530-542-1619
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42705207Q00000X
NV4413207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA080024457OtherMEDICARE RR
CA1205834306Medicaid
NVV105393Medicare PIN
CA00G427050Medicare PIN
A49079Medicare UPIN
NV1205834306Medicaid