=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679923015
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN BROOKS O.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2016
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 229 TECUMSEH ST
-----------------------------------------------------
City | DUNDEE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48131-2034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-529-8747
-----------------------------------------------------
Fax | 734-529-8749
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8614 WESTWOOD CENTER DR FL 9
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22182-2442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-847-8899
-----------------------------------------------------
Fax | 571-223-6780
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901004964
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------