Provider Demographics
NPI:1225124860
Name:BROWN, MATTHEW KOO-SUNG-MIN (DPM)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:KOO-SUNG-MIN
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 1:4969 DRIFTWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48382
Mailing Address - Country:US
Mailing Address - Phone:248-470-2140
Mailing Address - Fax:309-413-6428
Practice Address - Street 1:4969 DRIFTWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382
Practice Address - Country:US
Practice Address - Phone:248-470-2140
Practice Address - Fax:309-413-6428
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002060213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4522630Medicaid
MION43460024Medicare ID - Type Unspecified
MIU95739Medicare UPIN