Provider Demographics
NPI:1699019869
Name:BROOKE K STOUGH DPM
Entity Type:Organization
Organization Name:BROOKE K STOUGH DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:KELLEY
Authorized Official - Last Name:STOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:405-210-8071
Mailing Address - Street 1:1113 WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-8401
Mailing Address - Country:US
Mailing Address - Phone:405-210-8071
Mailing Address - Fax:
Practice Address - Street 1:1113 WINCHESTER AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-8401
Practice Address - Country:US
Practice Address - Phone:405-210-8071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-12
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK297213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200441760AMedicaid
OKOKA104993Medicare PIN