Provider Demographics
NPI:1104168590
Name:BROOKS, JUSTIN RYAN (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:RYAN
Last Name:BROOKS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11500 LIPSCOMB WAY
Mailing Address - Street 2:
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162
Mailing Address - Country:US
Mailing Address - Phone:757-581-1363
Mailing Address - Fax:
Practice Address - Street 1:11500 LIPSCOMB WAY
Practice Address - Street 2:
Practice Address - City:WHITE MARSH
Practice Address - State:MD
Practice Address - Zip Code:21162
Practice Address - Country:US
Practice Address - Phone:757-581-1363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-23
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101256800208D00000X
MDD0078268208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice