Provider Demographics
NPI:1568642221
Name:BROOKS, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BROOKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 S PALM DR
Mailing Address - Street 2:
Mailing Address - City:BLYTHE
Mailing Address - State:CA
Mailing Address - Zip Code:92225-2536
Mailing Address - Country:US
Mailing Address - Phone:760-922-1020
Mailing Address - Fax:760-922-1050
Practice Address - Street 1:176 S PALM DR
Practice Address - Street 2:
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225-2536
Practice Address - Country:US
Practice Address - Phone:760-922-1020
Practice Address - Fax:760-922-1050
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-10
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG11503207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G115032Medicaid
CA00G115032Medicaid