Provider Demographics
NPI:1417199167
Name:KENNETH S BROWN MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:KENNETH S BROWN MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:SPIERS
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-620-4373
Mailing Address - Street 1:1866 NORTH ORANGE GROVE AVE.
Mailing Address - Street 2:SUITE 102
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3031
Mailing Address - Country:US
Mailing Address - Phone:909-620-4373
Mailing Address - Fax:909-620-7179
Practice Address - Street 1:1866 NORTH ORANGE GROVE AVE.
Practice Address - Street 2:SUITE 102
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3031
Practice Address - Country:US
Practice Address - Phone:909-620-4373
Practice Address - Fax:909-620-7179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-26
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G304560Medicaid
G30456Medicare PIN
CA00G304560Medicaid