Provider Demographics
NPI:1538148176
Name:BROOKS, SALLY L (MD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:L
Last Name:BROOKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:L
Other - Last Name:MANZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2830 VICTORY PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-1786
Mailing Address - Country:US
Mailing Address - Phone:513-245-3052
Mailing Address - Fax:
Practice Address - Street 1:11100 SPRINGFIELD PIKE
Practice Address - Street 2:UNIVERSITY FAMILY PHYSICIANS-MAPL
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-4112
Practice Address - Country:US
Practice Address - Phone:513-782-2448
Practice Address - Fax:513-584-2809
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.058586207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0837205Medicaid
BR0696816Medicare ID - Type Unspecified
OH0837205Medicaid