Provider Demographics
NPI:1588640015
Name:BROWN, TEDDY WALLACE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:TEDDY
Middle Name:WALLACE
Last Name:BROWN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:13910 FIVAY ROAD SUITE 12
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667
Mailing Address - Country:US
Mailing Address - Phone:727-861-0678
Mailing Address - Fax:727-861-0679
Practice Address - Street 1:13910 FIVAY ROAD SUITE 12
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667
Practice Address - Country:US
Practice Address - Phone:727-861-0678
Practice Address - Fax:727-861-0679
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP896207Y00000X
FLME85915207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265323100Medicaid
E04267Medicare UPIN
FL265323100Medicaid