Provider Demographics
NPI: | 1619954633 |
---|---|
Name: | BROWN, ERIC (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | ERIC |
Middle Name: | |
Last Name: | BROWN |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 148 N GRAND AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | GLENDORA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 91741-2434 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 626-594-0478 |
Mailing Address - Fax: | 626-594-0575 |
Practice Address - Street 1: | 148 N GRAND AVE |
Practice Address - Street 2: | |
Practice Address - City: | GLENDORA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 91741-2434 |
Practice Address - Country: | US |
Practice Address - Phone: | 626-594-0478 |
Practice Address - Fax: | 626-594-0575 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-12-30 |
Last Update Date: | 2018-03-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 200201222 | 207PE0004X |
CA | A72839 | 207P00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine | |
No | 207PE0004X | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 89132J9 | Medicaid | |
NC | H71861 | Medicare UPIN | |
NC | 2008095 | Medicare ID - Type Unspecified |