Basic Information
| Provider Information | |||||||||
| NPI: | 1598731473 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15474 N HAGGERTY RD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481704893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343356103 | ||||||||
| FaxNumber: | 6307344715 | ||||||||
| Practice Location | |||||||||
| Address1: | 1231 PINE GROVE AVE | ||||||||
| Address2: | INFECTIOUS DISEASE, SUITE 1B | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109661993 | ||||||||
| FaxNumber: | 8109661997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 01/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 4301056328 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 1598731473 | 05 | MI | MEDICAID |