Provider Demographics
NPI:1427080845
Name:BROOKS, JACK GLEN (MD)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:GLEN
Last Name:BROOKS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1824 SOUTHPARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-4211
Mailing Address - Country:US
Mailing Address - Phone:817-429-1645
Mailing Address - Fax:817-451-3796
Practice Address - Street 1:601 W ARBROOK BLVD
Practice Address - Street 2:HEALTHSOUTH DIAGNOSTIC CENTER OF ARLINGTON
Practice Address - City:ALRINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-3701
Practice Address - Country:US
Practice Address - Phone:817-472-0801
Practice Address - Fax:817-472-0309
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXD27542085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC13798Medicaid
C13798Medicare ID - Type Unspecified
TXC13798Medicaid