Provider Demographics
NPI:1548255144
Name:BROOKS, LAGORA A OLIVER (MD)
Entity type:Individual
Prefix:
First Name:LAGORA
Middle Name:A OLIVER
Last Name:BROOKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAGORA
Other - Middle Name:A
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2301 GENERAL BOOTH BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-7755
Mailing Address - Country:US
Mailing Address - Phone:757-963-5500
Mailing Address - Fax:757-275-9907
Practice Address - Street 1:2301 GENERAL BOOTH BLVD
Practice Address - Street 2:STE B
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-7755
Practice Address - Country:US
Practice Address - Phone:757-963-5500
Practice Address - Fax:757-275-9907
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234783208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010090865Medicaid
VA0055555E32Medicare ID - Type Unspecified
I17861Medicare UPIN