Basic Information
| Provider Information | |||||||||
| NPI: | 1255347225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROOKES | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3702 NEW VISION DR | ||||||||
| Address2: | STE B | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602668210 | ||||||||
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| Practice Location | |||||||||
| Address1: | 524 BRANCH CT | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467251323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2602447600 | ||||||||
| FaxNumber: | 2602488555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 04/09/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01031142A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000576567 | 01 | IN | ANTHEM | OTHER | 100263090A | 05 | IN | MEDICAID | 000000327202 | 01 | IN | ANTHEM | OTHER |