Healthcare Provider Details

I. General information

NPI: 1629066907
Provider Name (Legal Business Name): MARK G BROOKS M D P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3872 OLD WINTER GARDEN RD SUITE 300 B
GOTHA FL
34734
US

IV. Provider business mailing address

3872 OLD WINTER GARDEN RD SUITE 300 B
GOTHA FL
34734
US

V. Phone/Fax

Practice location:
  • Phone: 407-578-6610
  • Fax: 407-578-2247
Mailing address:
  • Phone: 407-578-6610
  • Fax: 407-578-2247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME0070398
License Number StateFL

VIII. Authorized Official

Name: IDA BONILLA
Title or Position: PA
Credential:
Phone: 407-578-6610