Provider Demographics
NPI:1508513052
Name:BROWN, LEROY DONOVAN
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:DONOVAN
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 SPEIGHT ST
Mailing Address - Street 2:
Mailing Address - City:HAVELOCK
Mailing Address - State:NC
Mailing Address - Zip Code:28532-2426
Mailing Address - Country:US
Mailing Address - Phone:252-241-9783
Mailing Address - Fax:
Practice Address - Street 1:110 SPEIGHT ST
Practice Address - Street 2:
Practice Address - City:HAVELOCK
Practice Address - State:NC
Practice Address - Zip Code:28532-2426
Practice Address - Country:US
Practice Address - Phone:252-241-9783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-04
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC171W00000X
172A00000X
NC4512701172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2362659OtherDRIVER