Provider Demographics
NPI:1497208565
Name:BROOKS, JEFFREY ROBERT (DPM)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ROBERT
Last Name:BROOKS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 WARING CT STE M
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4509
Mailing Address - Country:US
Mailing Address - Phone:562-773-7920
Mailing Address - Fax:760-630-6239
Practice Address - Street 1:3230 WARING CT STE M
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4509
Practice Address - Country:US
Practice Address - Phone:760-630-9200
Practice Address - Fax:760-630-6239
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006721213E00000X
CAE5554213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty