Provider Demographics
NPI:1376151241
Name:BROWN, ROBERT JAMES (BCO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAMES
Last Name:BROWN
Suffix:
Gender:M
Credentials:BCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 S KENNETH PL
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-3942
Mailing Address - Country:US
Mailing Address - Phone:480-264-3041
Mailing Address - Fax:
Practice Address - Street 1:3025 S KENNETH PL
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-3942
Practice Address - Country:US
Practice Address - Phone:480-264-3041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ374205Medicaid