Provider Demographics
NPI: | 1245572890 |
---|---|
Name: | BROWN, MATTHEW JAY (DPM) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MATTHEW |
Middle Name: | JAY |
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: | 1051 HARDING MEMORIAL PKWY |
Mailing Address - Street 2: | SUITE B |
Mailing Address - City: | MARION |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 43302-6347 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 740-383-5115 |
Mailing Address - Fax: | 740-387-3668 |
Practice Address - Street 1: | 1051 HARDING MEMORIAL PKWY |
Practice Address - Street 2: | SUITE B |
Practice Address - City: | MARION |
Practice Address - State: | OH |
Practice Address - Zip Code: | 43302-6347 |
Practice Address - Country: | US |
Practice Address - Phone: | 740-383-5115 |
Practice Address - Fax: | 740-387-3668 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2013-03-21 |
Last Update Date: | 2024-02-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 36003755 | 213ES0103X, 213E00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | |
Yes | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 0160508 | Medicaid | |
OH | H463040 | Medicare PIN |