Provider Demographics
NPI:1851317549
Name:BROWN, DOUGLAS HENDERSON (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:HENDERSON
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:PO BOX 5667
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5667
Mailing Address - Country:US
Mailing Address - Phone:888-598-8820
Mailing Address - Fax:714-571-5055
Practice Address - Street 1:11620 WILSHIRE BLVD
Practice Address - Street 2:STE. 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-1706
Practice Address - Country:US
Practice Address - Phone:310-914-7336
Practice Address - Fax:310-914-7326
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA533272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A533270OtherBLUE SHIELD OF CA
CA00A533270Medicaid
300128257OtherRAILROAD MEDICARE
CA00A533270Medicaid
WA53327BMedicare PIN
00A533270OtherBLUE SHIELD OF CA