Basic Information
| Provider Information | |||||||||
| NPI: | 1598798480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7210 40TH ST W | ||||||||
| Address2: | STE 100 | ||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984664318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535640170 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7210 40TH ST W | ||||||||
| Address2: | STE 100 | ||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984664318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535640170 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 11/16/2010 | ||||||||
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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 | 207Q00000X | MD00031603 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0126533 | 01 | WA | STATE L&I | OTHER | 8928712 | 01 | WA | STATE CRIME VICTIMS | OTHER | 8937675 | 01 | WA | STATE CRIME VICTIMS | OTHER | 0163664 | 01 | WA | STATE L&I | OTHER | 8154320 | 05 | WA | MEDICAID | 80138476 | 01 | WA | MEDICARE RAILROAD | OTHER |