Provider Demographics
NPI:1124023759
Name:BROWN, CHARLES VICTOR JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:VICTOR
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:PO BOX 84524
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90073-0524
Mailing Address - Country:US
Mailing Address - Phone:310-696-9522
Mailing Address - Fax:
Practice Address - Street 1:1249 W GARDENA BLVD
Practice Address - Street 2:STE 102
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4884
Practice Address - Country:US
Practice Address - Phone:310-538-0400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49923207UN0902X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI26044Medicare UPIN
CAA49923Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION #