Provider Demographics
NPI:1578535274
Name:BROOKS, THERESA G (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:G
Last Name:BROOKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TERRY
Other - Middle Name:G
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:18911 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:OR
Mailing Address - Zip Code:97027-1630
Mailing Address - Country:US
Mailing Address - Phone:503-850-4472
Mailing Address - Fax:503-850-4473
Practice Address - Street 1:18911 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-1630
Practice Address - Country:US
Practice Address - Phone:503-850-4472
Practice Address - Fax:503-850-4473
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13505208000000X
WAMD60266153208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR162487Medicaid
OR037WFBFRKMedicare UPIN
WA0294608OtherL&I