Provider Demographics
NPI:1679504013
Name:BROWN, ROBERT GARY (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GARY
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 1:15802 N 10TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-3141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BANNER MESA MEDICAL CENTER
Practice Address - Street 2:1010 N. COUNTRY CLUB DRIVE
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201
Practice Address - Country:US
Practice Address - Phone:480-834-1211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12889207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF07396Medicare UPIN
AZ24503Medicare ID - Type Unspecified