Provider Demographics
NPI:1255361838
Name:BROOK, MICHAEL WAGNER (MD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WAGNER
Last Name:BROOK
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 1:470 GREENFIELD AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-3576
Mailing Address - Country:US
Mailing Address - Phone:559-537-0325
Mailing Address - Fax:559-537-0327
Practice Address - Street 1:470 GREENFIELD AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-3576
Practice Address - Country:US
Practice Address - Phone:559-537-0325
Practice Address - Fax:559-537-0327
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63429207LP2900X, 208VP0000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0042170Medicaid
CAF04960Medicare UPIN
CA00G634290Medicare ID - Type UnspecifiedMEDICARE NO.