Provider Demographics
NPI:1801890421
Name:BROOKS, JOHN MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:BROOKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 GREENVILLE AVENUE
Mailing Address - Street 2:
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214
Mailing Address - Country:US
Mailing Address - Phone:814-226-7651
Mailing Address - Fax:814-226-4051
Practice Address - Street 1:180 GREENVILLE AVENUE
Practice Address - Street 2:
Practice Address - City:CLARION
Practice Address - State:PA
Practice Address - Zip Code:16214
Practice Address - Country:US
Practice Address - Phone:814-226-7651
Practice Address - Fax:814-226-4051
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS003088L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006336770001Medicaid
PA0006336770002Medicaid
PABR003024Medicare ID - Type UnspecifiedMEDICARE
003024Medicare PIN
PAE54160Medicare UPIN
PA0006336770002Medicaid