Provider Demographics
NPI:1376653428
Name:BROOKRESON, JOSEPH W
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:W
Last Name:BROOKRESON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 THATCHER RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25403
Mailing Address - Country:US
Mailing Address - Phone:304-263-2823
Mailing Address - Fax:304-263-1634
Practice Address - Street 1:1003 SUSHRUTA DR
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-263-3367
Practice Address - Fax:304-263-1634
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2434122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV138410OtherUNITED CONCORDIA
WV0136323000Medicaid
VA140435OtherANTHEM BCBS