Provider Demographics
NPI:1851564470
Name:BROOKS, BENJAMIN A (MD)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:A
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 1:637 E SNYDER ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526
Mailing Address - Country:US
Mailing Address - Phone:217-423-7337
Mailing Address - Fax:217-423-7338
Practice Address - Street 1:637 E SNYDER ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526
Practice Address - Country:US
Practice Address - Phone:217-423-7337
Practice Address - Fax:217-423-7338
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-03
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361044742080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104474Medicaid