Provider Demographics
NPI:1538380902
Name:BROOKS, MICHENA LUBIN (DPM)
Entity type:Individual
Prefix:
First Name:MICHENA
Middle Name:LUBIN
Last Name:BROOKS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 EASTERN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-6370
Mailing Address - Country:US
Mailing Address - Phone:718-636-8291
Mailing Address - Fax:718-398-3168
Practice Address - Street 1:255 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-6370
Practice Address - Country:US
Practice Address - Phone:718-636-8291
Practice Address - Fax:718-398-3168
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004062-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN004062-1OtherLISCENSE
NYN004062-1OtherLISCENSE
NYSPD147AMedicare ID - Type Unspecified