Provider Demographics
NPI:1174513089
Name:BROOKS, MICHAEL WAYNE (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
Last Name:BROOKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:868 YORK AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-2750
Mailing Address - Country:US
Mailing Address - Phone:404-752-1400
Mailing Address - Fax:404-758-0740
Practice Address - Street 1:868 YORK AVE SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-2750
Practice Address - Country:US
Practice Address - Phone:404-752-1400
Practice Address - Fax:404-758-0740
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029420207KI0005X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000352811AMedicaid
GAD39490Medicare UPIN