Provider Demographics
NPI:1376779041
Name:BROWN, BREANNE D (DO)
Entity Type:Individual
Prefix:
First Name:BREANNE
Middle Name:D
Last Name:BROWN
Suffix:
Gender:F
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18040 SW LOWER BOONES FERRY RD
Practice Address - Street 2:STE 100
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7258
Practice Address - Country:US
Practice Address - Phone:503-216-0700
Practice Address - Fax:503-216-0750
Is Sole Proprietor?:No
Enumeration Date:2009-06-08
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLL18349207Q00000X
ORDO155935207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500652964Medicaid
ORP01287073OtherRR MEDICARE - PH&S
ORP01287073OtherRR MEDICARE - PH&S
OR500652964Medicaid