Provider Demographics
NPI:1235136292
Name:BROOKS, DR (DPM)
Entity type:Individual
Prefix:DR
First Name:DR
Middle Name:
Last Name:BROOKS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:DR
Other - Middle Name:
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:6464 W MAIN ST
Mailing Address - Street 2:SUITE 7A
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-3811
Mailing Address - Country:US
Mailing Address - Phone:618-293-1785
Mailing Address - Fax:618-293-1785
Practice Address - Street 1:6464 W MAIN ST
Practice Address - Street 2:SUITE 7A
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3811
Practice Address - Country:US
Practice Address - Phone:618-293-1785
Practice Address - Fax:618-293-1785
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-06
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004697213E00000X
IL016004697213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08207252OtherBCBS
IL016004697Medicaid
ILP01303017OtherRAILROAD MEDICARE PTAN NUMBER
ILU50255Medicare UPIN
IL1062730001Medicare NSC
346610Medicare PIN
08207252OtherILLINOIS BCBS
U50255Medicare UPIN
IL016004697Medicaid