Provider Demographics
NPI:1659853513
Name:BROWN, DAVID JONATHAN
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JONATHAN
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 NORTH PEARL ST.
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12204
Mailing Address - Country:US
Mailing Address - Phone:518-462-5923
Mailing Address - Fax:518-489-2352
Practice Address - Street 1:456 NORTH PEARL ST.
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12204
Practice Address - Country:US
Practice Address - Phone:518-462-5923
Practice Address - Fax:518-489-2352
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04224448Medicaid