Healthcare Provider Details

I. General information

NPI: 1376558429
Provider Name (Legal Business Name): BROOKS W BOOKER IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 NE MEDICAL CENTER DR
BEND OR
97701-6051
US

IV. Provider business mailing address

PO BOX 6048
BEND OR
97708-6048
US

V. Phone/Fax

Practice location:
  • Phone: 541-382-2811
  • Fax:
Mailing address:
  • Phone: 541-382-2811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD167654
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier11057533
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerCAQH
# 2
Identifier500672815
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: