Provider Demographics
NPI:1154662948
Name:BROWN, CORY ALLEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:CORY
Middle Name:ALLEN
Last Name:BROWN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 23RD AVE
Mailing Address - Street 2:SUITE 1001
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6350
Mailing Address - Country:US
Mailing Address - Phone:208-553-4780
Mailing Address - Fax:
Practice Address - Street 1:1630 23RD AVE
Practice Address - Street 2:SUITE 1001
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-6350
Practice Address - Country:US
Practice Address - Phone:208-553-4780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2015-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-222213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery