Provider Demographics
NPI:1629066907
Name:MARK G BROOKS M D P A
Entity Type:Organization
Organization Name:MARK G BROOKS M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-578-6610
Mailing Address - Street 1:10000 W COLONIAL DR
Mailing Address - Street 2:SUITE 180
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-3498
Mailing Address - Country:US
Mailing Address - Phone:407-578-6610
Mailing Address - Fax:407-578-2247
Practice Address - Street 1:10000 W COLONIAL DR
Practice Address - Street 2:SUITE 180
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3498
Practice Address - Country:US
Practice Address - Phone:407-578-6610
Practice Address - Fax:407-578-2247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0070398207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110221576OtherRAILROAD MEDICARE
FL97989OtherBCBS
FL110221576OtherRAILROAD MEDICARE
FLK3161Medicare ID - Type Unspecified