Healthcare Provider Details

I. General information

NPI: 1316930480
Provider Name (Legal Business Name): BROOKS CARLTON MICHAELS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 ROYAL AVE STE 234
SIMI VALLEY CA
93065-4600
US

IV. Provider business mailing address

2045 ROYAL AVE STE 234
SIMI VALLEY CA
93065-4600
US

V. Phone/Fax

Practice location:
  • Phone: 805-578-9751
  • Fax: 805-578-2821
Mailing address:
  • Phone: 805-578-9751
  • Fax: 805-578-2821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG60910
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: