Provider Demographics
NPI:1386654994
Name:BROOKS, SHAWN M (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:M
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-572-1472
Mailing Address - Fax:
Practice Address - Street 1:9844 S 1300 E
Practice Address - Street 2:#200
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-4673
Practice Address - Country:US
Practice Address - Phone:801-572-1472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT50924001205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000063976Medicare PIN