Provider Demographics
NPI:1124490693
Name:BROOKS, THERDO III (CRT)
Entity type:Individual
Prefix:
First Name:THERDO
Middle Name:
Last Name:BROOKS
Suffix:III
Gender:M
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14450 W AVALON DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-8315
Mailing Address - Country:US
Mailing Address - Phone:602-466-4926
Mailing Address - Fax:
Practice Address - Street 1:14450 W AVALON DR
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-8315
Practice Address - Country:US
Practice Address - Phone:602-466-4926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18024247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist