Provider Demographics
NPI:1649276445
Name:BROOKS, GLEN (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:BROOKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 HARBOR ACRES RD
Mailing Address - Street 2:
Mailing Address - City:SANDS POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11050-2627
Mailing Address - Country:US
Mailing Address - Phone:516-662-1655
Mailing Address - Fax:212-385-2434
Practice Address - Street 1:80 MAIDEN LN
Practice Address - Street 2:SUITE 703
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-4811
Practice Address - Country:US
Practice Address - Phone:917-261-7370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156876207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00835552Medicaid
NY10D301Medicare ID - Type UnspecifiedEMPIRE MEDICARE
NY00835552Medicaid
NYA60458Medicare UPIN