Provider Demographics
NPI:1346280492
Name:BROWN, MARY A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:A
Last Name:BROWN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 WEST BUNNY AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-2805
Mailing Address - Country:US
Mailing Address - Phone:805-242-0614
Mailing Address - Fax:805-457-1550
Practice Address - Street 1:100 CASA STREET
Practice Address - Street 2:SUITE B
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1818
Practice Address - Country:US
Practice Address - Phone:805-242-0614
Practice Address - Fax:805-457-1550
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51256207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
5472331OtherAETNA PIN
106272900OtherDOL PROVIDER PIN
CA00G512560Medicaid
CACB234375OtherMEDICARE ID
CA00G512560Medicaid