Provider Demographics
NPI:1609853282
Name:BROOKS, RANDOLPH (OD)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:
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 1:410 ROUTE 10
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LEDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07852-9658
Mailing Address - Country:US
Mailing Address - Phone:973-584-2020
Mailing Address - Fax:973-584-4992
Practice Address - Street 1:410 ROUTE 10
Practice Address - Street 2:SUITE 202
Practice Address - City:LEDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07852-9658
Practice Address - Country:US
Practice Address - Phone:973-584-2020
Practice Address - Fax:973-584-4992
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00375200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ521312Medicare PIN
NJU26860Medicare UPIN