Provider Demographics
NPI:1235155250
Name:BROWN, CHARLES JACOB (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:JACOB
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 1:719 EAST BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203
Mailing Address - Country:US
Mailing Address - Phone:704-376-9849
Mailing Address - Fax:704-333-0708
Practice Address - Street 1:719 EAST BOULEVARD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203
Practice Address - Country:US
Practice Address - Phone:704-376-9849
Practice Address - Fax:704-333-0708
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC35848207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8918893Medicaid
NC2173317BMedicare ID - Type Unspecified
NC8918893Medicaid