Provider Demographics
NPI:1790861052
Name:BROOKS, DAVID WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
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 1:1933 E BRENT LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3154
Mailing Address - Country:US
Mailing Address - Phone:479-442-4614
Mailing Address - Fax:479-442-2707
Practice Address - Street 1:1933 E BRENT LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-3154
Practice Address - Country:US
Practice Address - Phone:479-442-4614
Practice Address - Fax:479-442-2707
Is Sole Proprietor?:No
Enumeration Date:2006-10-30
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7666208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR117483001Medicaid
AR50460Medicare ID - Type Unspecified
ARE37272Medicare UPIN