Provider Demographics
NPI:1689680522
Name:BROOKS, IVAN ISRAEL (MD)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:ISRAEL
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 1:1049 MAYBROOK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-2715
Mailing Address - Country:US
Mailing Address - Phone:310-853-5850
Mailing Address - Fax:
Practice Address - Street 1:9400 BRIGHTON WAY STE 205
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4709
Practice Address - Country:US
Practice Address - Phone:310-853-5850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65321207L00000X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A653210OtherBLUE SHIELD
H12187Medicare UPIN
CAWA65321CMedicare PIN
CAA65321Medicare ID - Type Unspecified