1063655140 NPI number — MR. GREGORY S. BROOKS IDMT

Table of content: MR. GREGORY S. BROOKS IDMT (NPI 1063655140)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063655140 NPI number — MR. GREGORY S. BROOKS IDMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROOKS
Provider First Name:
GREGORY
Provider Middle Name:
S.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
IDMT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063655140
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2355 FACULTY DRIVE SUITE 1N207
Provider Second Line Business Mailing Address:
10TH AMDS
Provider Business Mailing Address City Name:
USAFA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80840
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-333-5187
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2355 FACULTY DR SUITE 1N207
Provider Second Line Business Practice Location Address:
10TH AMDS
Provider Business Practice Location Address City Name:
USAFA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-333-5187
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1710I1003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)