Provider Demographics
NPI:1801821418
Name:BROOKS, VERA R (MD)
Entity Type:Individual
Prefix:
First Name:VERA
Middle Name:R
Last Name:BROOKS
Suffix:
Gender:F
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:PO BOX 588
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-0588
Mailing Address - Country:US
Mailing Address - Phone:601-859-5213
Mailing Address - Fax:601-859-8771
Practice Address - Street 1:1547 JERRY CLOWER BLVD
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-2718
Practice Address - Country:US
Practice Address - Phone:662-746-6532
Practice Address - Fax:662-746-1339
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17263207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08574823Medicaid
MS080003786Medicare ID - Type Unspecified
MS08574823Medicaid