Basic Information
| Provider Information | |||||||||
| NPI: | 1932106499 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 HATFIELD LN | ||||||||
| Address2: | STE 204 | ||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109246735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144567599 | ||||||||
| FaxNumber: | 8452942312 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 HATFIELD LN | ||||||||
| Address2: | STE 204 | ||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109246735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144567599 | ||||||||
| FaxNumber: | 8452942312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 11/17/2008 | ||||||||
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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 | 207RG0100X | 147287 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 10169 | ND | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 00915242 | 05 | NY | MEDICAID |