Provider Demographics
NPI:1447200795
Name:BROOKS, KEITH JAMES (OD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:JAMES
Last Name:BROOKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6799 BISMARK RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80922-1189
Mailing Address - Country:US
Mailing Address - Phone:719-574-2020
Mailing Address - Fax:719-574-1391
Practice Address - Street 1:6799 BISMARK RD
Practice Address - Street 2:SUITE D
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-1189
Practice Address - Country:US
Practice Address - Phone:719-574-2020
Practice Address - Fax:719-574-1391
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT1985152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO804889OtherGROUP IDENTIFIER
CO804890Medicare ID - Type Unspecified
CO804889OtherGROUP IDENTIFIER