Healthcare Provider Details

I. General information

NPI: 1730158304
Provider Name (Legal Business Name): JAY P BROOKS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 918025
ORLANDO FL
32891-0001
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-7839
  • Fax:
Mailing address:
  • Phone: 352-273-7839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number23549
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME111220
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: