Provider Demographics
NPI:1669492716
Name:BROOKS, GLENN GARY (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:GARY
Last Name:BROOKS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF OB/GYN
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-8700
Mailing Address - Fax:318-675-8706
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF OB/GYN
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-8700
Practice Address - Fax:318-675-8706
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2025-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010069207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1169285Medicaid
LAE15255Medicare UPIN
LA1169285Medicaid