Provider Demographics
NPI:1093930562
Name:BROOKS, KENNETH RYAN (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RYAN
Last Name:BROOKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 58538
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-8538
Mailing Address - Country:US
Mailing Address - Phone:281-985-9342
Mailing Address - Fax:281-393-0029
Practice Address - Street 1:905 W MEDICAL CENTER BLVD STE 404
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4009
Practice Address - Country:US
Practice Address - Phone:281-985-9342
Practice Address - Fax:281-393-0029
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088759207X00000X, 207XX0005X
TXN3515207X00000X, 207XX0005X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX206898304Medicaid
MI5209565Medicaid
TX206898301Medicaid
TX8FU628OtherBLUE CROSS BLUE SHIELD
TX8FU628OtherBLUE CROSS BLUE SHIELD
MI5209565Medicaid
TX8L20854Medicare PIN