Provider Demographics
NPI:1326095399
Name:BREWER, LON RUSSELL (DO)
Entity Type:Individual
Prefix:
First Name:LON
Middle Name:RUSSELL
Last Name:BREWER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:1924 NW 88TH CT
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-5463
Practice Address - Country:US
Practice Address - Phone:515-237-3974
Practice Address - Fax:515-883-2692
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1326095399Medicaid
IA5084277Medicaid
IA080171037OtherRR MEDICARE
IA1326095399OtherWELLMARK BCBS
IA080171037OtherRR MEDICARE
IA1326095399OtherWELLMARK BCBS