Basic Information
| Provider Information | |||||||||
| NPI: | 1285625723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | MOHLER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2524 TRAMWAY TERRACE CT NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871222317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058561936 | ||||||||
| FaxNumber: | 3034229474 | ||||||||
| Practice Location | |||||||||
| Address1: | 2524 TRAMWAY TERRACE CT NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871222317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058561936 | ||||||||
| FaxNumber: | 3034229474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 88128 | NM | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00004739 | 05 | NM | MEDICAID |