Provider Demographics
NPI:1740423151
Name:BROOK, DOUGLAS (IDMT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:BROOK
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 FOX BLVD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-4708
Mailing Address - Country:US
Mailing Address - Phone:850-420-3191
Mailing Address - Fax:
Practice Address - Street 1:755 SCOTT CIR
Practice Address - Street 2:
Practice Address - City:JBPHH
Practice Address - State:HI
Practice Address - Zip Code:96853-5399
Practice Address - Country:US
Practice Address - Phone:850-420-3191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-15
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians