Basic Information
| Provider Information | |||||||||
| NPI: | 1922026335 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROOKER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15280 NW 79TH CT STE 200 | ||||||||
| Address2: | |||||||||
| City: | MIAMI LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330165873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055583724 | ||||||||
| FaxNumber: | 7869074485 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 E LAKE HOWARD DR | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338813155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632991251 | ||||||||
| FaxNumber: | 8632997666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0602X | ME75481 | FL | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy | 207YX0905X | ME75946 | FL | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | 207Y00000X | ME75946 | FL | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 255392-900 | 05 | FL | MEDICAID |