Provider Demographics
NPI:1578559167
Name:BROWN, ROSE MARY (OD)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARY
Last Name:BROWN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 OIL WELL RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-7352
Mailing Address - Country:US
Mailing Address - Phone:731-394-0989
Mailing Address - Fax:
Practice Address - Street 1:412 OIL WELL RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-7352
Practice Address - Country:US
Practice Address - Phone:731-554-3333
Practice Address - Fax:731-554-3336
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000001095152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3944831Medicare ID - Type Unspecified
TNU87777Medicare UPIN