Provider Demographics
NPI:1063415065
Name:BROOKS, DUANE THOMAS (OD)
Entity type:Individual
Prefix:
First Name:DUANE
Middle Name:THOMAS
Last Name:BROOKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2209
Mailing Address - Country:US
Mailing Address - Phone:530-926-2033
Mailing Address - Fax:530-926-3722
Practice Address - Street 1:110 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2209
Practice Address - Country:US
Practice Address - Phone:530-926-2033
Practice Address - Fax:530-926-3722
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE777T152W00000X
CA5366T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0053660Medicaid
CASD0053660Medicaid
CASD0053660Medicare PIN