Provider Demographics
NPI:1598781007
Name:BROWN, TRISTAN M (OD)
Entity Type:Individual
Prefix:
First Name:TRISTAN
Middle Name:M
Last Name:BROWN
Suffix:
Gender:M
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:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-0669
Mailing Address - Country:US
Mailing Address - Phone:712-792-3318
Mailing Address - Fax:712-792-3319
Practice Address - Street 1:1236 HEIRES AVE
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3328
Practice Address - Country:US
Practice Address - Phone:712-792-3318
Practice Address - Fax:712-792-3319
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02359152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA25008OtherWELLMARK JEFFERSON
IA0498287Medicaid
IA25005OtherWELLMARK CARROLL
IA25007OtherWELLMARK DENISON
IA250737OtherMIDLANDS CHOICE
IA1498287Medicaid
IA291300OtherCOVENTRY ALL OFFICES
IA2498287Medicaid
IA25007OtherWELLMARK DENISON
IAV10075Medicare UPIN
IAP00434650Medicare PIN
IAI18199Medicare PIN
IA1498287Medicaid
IA291300OtherCOVENTRY ALL OFFICES