Provider Demographics
NPI:1467487041
Name:BROOKS, ROBERT FORD (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:FORD
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:PO BOX 723
Mailing Address - Street 2:
Mailing Address - City:GREENUP
Mailing Address - State:KY
Mailing Address - Zip Code:41144-0723
Mailing Address - Country:US
Mailing Address - Phone:606-473-5322
Mailing Address - Fax:606-473-5055
Practice Address - Street 1:1621 ASHLAND RD
Practice Address - Street 2:UNIT 3
Practice Address - City:GREENUP
Practice Address - State:KY
Practice Address - Zip Code:41144-1207
Practice Address - Country:US
Practice Address - Phone:606-473-5322
Practice Address - Fax:606-473-5055
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY931DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77009314Medicaid
KY0214650001Medicare NSC
KYT69343Medicare UPIN
KY77009314Medicaid