Provider Demographics
NPI:1790733293
Name:BROOKS, DONALD F (MD)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:F
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 1:450 MEDICAL PARK DR
Mailing Address - Street 2:SUITE # 400
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098-8531
Mailing Address - Country:US
Mailing Address - Phone:269-463-3044
Mailing Address - Fax:269-463-8170
Practice Address - Street 1:450 MEDICAL PARK DR
Practice Address - Street 2:SUITE # 400
Practice Address - City:WATERVLIET
Practice Address - State:MI
Practice Address - Zip Code:49098-8531
Practice Address - Country:US
Practice Address - Phone:269-463-3044
Practice Address - Fax:269-463-8170
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI430106799174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI103069741Medicaid
MID50432Medicare UPIN