Provider Demographics
NPI:1538144381
Name:BROOKS, CHARLES WILSON (OD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILSON
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 1:201 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:505-359-1252
Mailing Address - Fax:505-359-2601
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:505-359-1252
Practice Address - Fax:505-359-2601
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM292152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00P023OtherBLUE CROSS BLUE SHIELD PR
NMP0565Medicaid
NM2591243Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NMT12394Medicare UPIN
NMN0183Medicare ID - Type UnspecifiedMEDICARE ELECTRONIC NUMBE
NMP0565Medicaid