Healthcare Provider Details

I. General information

NPI: 1457363160
Provider Name (Legal Business Name): BROOKS & POTTINGER, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W PLYMOUTH AVENUE
DELAND FL
32720
US

IV. Provider business mailing address

850 W PLYMOUTH AVENUE
DELAND FL
32720
US

V. Phone/Fax

Practice location:
  • Phone: 386-736-6110
  • Fax: 386-736-7998
Mailing address:
  • Phone: 386-736-6110
  • Fax: 386-736-7998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0026840
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME103639
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number1053372
License Number StateFL

VIII. Authorized Official

Name: DR. JEFFREY B BROOKS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 386-736-6110