Provider Demographics
NPI:1457470247
Name:BROOKS, MICHAEL KEITH
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEITH
Last Name:BROOKS
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 1:770 BOYLSTON ST
Mailing Address - Street 2:4H
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02199-7700
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:770 BOYLSTON ST
Practice Address - Street 2:4H
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02199-7700
Practice Address - Country:US
Practice Address - Phone:516-663-3686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2254202085R0202X
NY2557552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology