Provider Demographics
NPI:1114052677
Name:BROWN, MANUEL L JR (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:L
Last Name:BROWN
Suffix:JR
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 1:2215 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40212-1033
Mailing Address - Country:US
Mailing Address - Phone:812-218-8926
Mailing Address - Fax:812-218-8930
Practice Address - Street 1:1000 NEIGHBORHOOD PL
Practice Address - Street 2:
Practice Address - City:FAIRDALE
Practice Address - State:KY
Practice Address - Zip Code:40118-9697
Practice Address - Country:US
Practice Address - Phone:812-218-8926
Practice Address - Fax:812-218-8930
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY16772207QG0300X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64167729Medicaid
KYK224343Medicare PIN
KY64167729Medicaid
KYK224340Medicare PIN
KYC71306Medicare UPIN
KYP400038130Medicare PIN
KYK224344Medicare PIN
KYK224342Medicare PIN
KYK224345Medicare PIN
KYK224341Medicare PIN