Provider Demographics
NPI:1063686004
Name:BROWN, GLADYS
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:
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 1:1101 NW 139TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33168-6711
Mailing Address - Country:US
Mailing Address - Phone:305-687-2215
Mailing Address - Fax:
Practice Address - Street 1:1101 NW 139TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33168-6711
Practice Address - Country:US
Practice Address - Phone:305-687-2215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCFCE 1007-1014-92171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300094000OtherMEDICAID PROVIDER NUMBER