Provider Demographics
NPI:1427231638
Name:BROOKS, CHARLES DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DOUGLAS
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 1:1901 MEDI PARK DR
Mailing Address - Street 2:SUITE 2050
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-2110
Mailing Address - Country:US
Mailing Address - Phone:806-355-3352
Mailing Address - Fax:806-355-5367
Practice Address - Street 1:1901 MEDI PARK DR
Practice Address - Street 2:SUITE 2050
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2110
Practice Address - Country:US
Practice Address - Phone:806-355-3352
Practice Address - Fax:806-355-5367
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM78742085R0202X
OH35.0928432085R0202X
NMMD2010-01472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35.092843Other35.092843
TXM7874OtherTX LIC# M7874
NMMD2010-0147OtherNEW MEXICO