Provider Demographics
NPI:1144234659
Name:BROWN, NORDELL T (MD)
Entity Type:Individual
Prefix:
First Name:NORDELL
Middle Name:T
Last Name:BROWN
Suffix:
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 1:1350 N 500 E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2400
Mailing Address - Country:US
Mailing Address - Phone:435-792-1940
Mailing Address - Fax:
Practice Address - Street 1:1350 N 500 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2400
Practice Address - Country:US
Practice Address - Phone:435-792-1940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2819671205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTF67153Medicare UPIN
UT000063826Medicare PIN