Provider Demographics
NPI:1003312760
Name:BROWN, SARA JANE
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:JANE
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30615 WILLOWICK DR
Mailing Address - Street 2:
Mailing Address - City:WILLOWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44095-3748
Mailing Address - Country:US
Mailing Address - Phone:440-796-7763
Mailing Address - Fax:
Practice Address - Street 1:9500 MENTOR AVE STE 100
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-8702
Practice Address - Country:US
Practice Address - Phone:440-352-4880
Practice Address - Fax:440-352-3629
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.142248207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0293379Medicaid