Provider Demographics
NPI:1730303330
Name:BROOKS, STEPHEN JOHN DAVID (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN JOHN
Middle Name:DAVID
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 1:3563 PHILLIPS HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-5663
Mailing Address - Country:US
Mailing Address - Phone:904-376-4275
Mailing Address - Fax:904-376-3700
Practice Address - Street 1:3563 PHILLIPS HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-5663
Practice Address - Country:US
Practice Address - Phone:904-376-4275
Practice Address - Fax:904-376-3700
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39995207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL039675300Medicaid
FLK1951AOtherBPC GRP PTAN
FL039675300Medicaid
FL15673ZMedicare PIN