Provider Demographics
NPI:1033218730
Name:BRAWNER, MARLO (MD)
Entity Type:Individual
Prefix:
First Name:MARLO
Middle Name:
Last Name:BRAWNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 OGLETREE DR
Mailing Address - Street 2:
Mailing Address - City:LIVINSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351
Mailing Address - Country:US
Mailing Address - Phone:936-328-8812
Mailing Address - Fax:936-328-8815
Practice Address - Street 1:400 OGLETREE DR
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-6783
Practice Address - Country:US
Practice Address - Phone:936-328-8812
Practice Address - Fax:936-328-8815
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL67362080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159580303Medicaid
TX21239OtherCHOICE ONE CHIPS
TX169920902Medicaid
TX8P9491OtherBCBS NUMBER
TX8P9491OtherBCBS NUMBER
TX21239OtherCHOICE ONE CHIPS