Healthcare Provider Details

I. General information

NPI: 1164721130
Provider Name (Legal Business Name): BYRON ANGELI BROOKS JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

764 PINE ST
MACON GA
31201
US

IV. Provider business mailing address

764 PINE ST
MACON GA
31201-2107
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-1056
  • Fax: 478-749-9171
Mailing address:
  • Phone: 478-633-1056
  • Fax: 478-749-9171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number21687
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number008721
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: