Provider Demographics
NPI:1548241656
Name:BROWN, DEREK ROBERT (PA)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:ROBERT
Last Name:BROWN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1159 E KNIGHT LN
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-1518
Mailing Address - Country:US
Mailing Address - Phone:480-227-2203
Mailing Address - Fax:
Practice Address - Street 1:13677 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-2618
Practice Address - Country:US
Practice Address - Phone:480-227-2203
Practice Address - Fax:480-726-2481
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2685207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ725012Medicaid
AZ39-57220OtherEVERCARE GROUP
AZAW1436OtherHEALTHNET GROUP
AZ725012Medicaid
AZ103634Medicare ID - Type Unspecified