Provider Demographics
NPI:1912904129
Name:BROOKS, CLYDE L (MD)
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:L
Last Name:BROOKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:252-744-3258
Mailing Address - Fax:252-744-3194
Practice Address - Street 1:521 MOYE BLVD
Practice Address - Street 2:ECU PHYSICIANS
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-4300
Practice Address - Country:US
Practice Address - Phone:252-744-3229
Practice Address - Fax:252-744-3924
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32224207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911605Medicaid
NC110176310OtherRAILROAD MEDICARE
NC11605OtherBCBS NC
NC11605OtherBCBS NC
NC8911605Medicaid