Provider Demographics
NPI:1285625723
Name:BROOKS, PHILLIP MOHLER (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:MOHLER
Last Name:BROOKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2524 TRAMWAY TERRACE CT NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-2317
Mailing Address - Country:US
Mailing Address - Phone:505-856-1936
Mailing Address - Fax:303-422-9474
Practice Address - Street 1:2524 TRAMWAY TERRACE CT NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-2317
Practice Address - Country:US
Practice Address - Phone:505-856-1936
Practice Address - Fax:303-422-9474
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM88128174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00004739Medicaid
NMA08344Medicare UPIN