Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | G49006 | CA |
NPI | 1013013150 |
---|---|
Provider Name | Oliver Tate Brooks |
First Address | Los Angeles, CA 90002-3628 |
Second Address | Los Angeles, CA 90002-3628 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/09/2006 |
Last Update Date | 15/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F11242 | (02) | CA |
WG00613 | MEDI-CAL NO. (01) | CA |