Provider Demographics
NPI:1689670671
Name:BROOKS, BOBBY JOE (MD)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:JOE
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 1:127 KINGSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9634
Mailing Address - Country:US
Mailing Address - Phone:270-789-3410
Mailing Address - Fax:270-465-2449
Practice Address - Street 1:127 KINGSWOOD DR
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9634
Practice Address - Country:US
Practice Address - Phone:270-789-3410
Practice Address - Fax:270-465-2449
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2010-07-21
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
KY17421207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64174212Medicaid
KY64174212Medicaid
0628801Medicare ID - Type Unspecified