Provider Demographics
NPI:1417058082
Name:BROWN, TIMOTHY MATHER (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MATHER
Last Name:BROWN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12612 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1058
Mailing Address - Country:US
Mailing Address - Phone:503-257-6393
Mailing Address - Fax:503-257-8785
Practice Address - Street 1:12612 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1058
Practice Address - Country:US
Practice Address - Phone:503-257-6393
Practice Address - Fax:503-257-8785
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12786207N00000X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
070008378OtherMEDICARE RAILROAD
070008378OtherMEDICARE RAILROAD
ORR0000BHVCGMedicare ID - Type Unspecified