Provider Demographics
NPI:1184658569
Name:BROWN, JEFFREY MICHAEL (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:BROWN
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5376
Mailing Address - Country:US
Mailing Address - Phone:772-337-4798
Mailing Address - Fax:772-337-2004
Practice Address - Street 1:1265 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5376
Practice Address - Country:US
Practice Address - Phone:772-337-4798
Practice Address - Fax:772-337-2004
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00121321223S0112X
FLME662111223S0112X
NJ140821223S0112X
MD99481223S0112X
PADS026292L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL569150OtherUNITED CONCORDIA
FL69476OtherBLUE CROSS/BLUE SHIELD
FL69476OtherBLUE CROSS/BLUE SHIELD