Provider Demographics
NPI:1902150691
Name:DR. MARK G. BROOKS MD PA
Entity Type:Organization
Organization Name:DR. MARK G. BROOKS MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KHADJA
Authorized Official - Middle Name:SHAIROOL
Authorized Official - Last Name:MAYCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, ARNP, FNP-BC
Authorized Official - Phone:407-716-6115
Mailing Address - Street 1:8042 TABBY LN
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-8624
Mailing Address - Country:US
Mailing Address - Phone:407-716-6115
Mailing Address - Fax:
Practice Address - Street 1:10000 W COLONIAL DR
Practice Address - Street 2:SUITE 187
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3400
Practice Address - Country:US
Practice Address - Phone:407-578-6610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9203957363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty