Provider Demographics
NPI:1255347225
Name:BROOKES, JEFFREY A (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:BROOKES
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 1:3702 NEW VISION DR
Mailing Address - Street 2:STE B
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1703
Mailing Address - Country:US
Mailing Address - Phone:260-266-8210
Mailing Address - Fax:
Practice Address - Street 1:524 BRANCH CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA CITY
Practice Address - State:IN
Practice Address - Zip Code:46725-1323
Practice Address - Country:US
Practice Address - Phone:260-244-7600
Practice Address - Fax:260-248-8555
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031142A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000576567OtherANTHEM
IN100263090AMedicaid
IN000000327202OtherANTHEM
IN930860Medicare PIN
IN000000327202OtherANTHEM
IN135960SMedicare PIN
IN070860WWMedicare PIN
IN100263090AMedicaid