Provider Demographics
NPI:1508035817
Name:CHARLES W. BROOKS, O.D., P.C.
Entity Type:Organization
Organization Name:CHARLES W. BROOKS, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:575-359-1252
Mailing Address - Street 1:201 S ABILENE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-6207
Mailing Address - Country:US
Mailing Address - Phone:575-359-1252
Mailing Address - Fax:575-359-2601
Practice Address - Street 1:201 S ABILENE AVE
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6207
Practice Address - Country:US
Practice Address - Phone:575-359-1252
Practice Address - Fax:575-359-2601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2292152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00P023OtherBCBS NEW MEXICO
NMP0565Medicaid
NMT12394Medicare UPIN
NMNM00P023OtherBCBS NEW MEXICO
NMP0565Medicaid