Provider Demographics
NPI:1891781563
Name:BROWN, EDWARD JAMES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JAMES
Last Name:BROWN
Suffix:JR
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 1:865-A WALTON AVE
Mailing Address - Street 2:STORE FRONT
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451
Mailing Address - Country:US
Mailing Address - Phone:718-292-9200
Mailing Address - Fax:718-292-9205
Practice Address - Street 1:865A WALTON AVE
Practice Address - Street 2:STORE FRONT
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5441
Practice Address - Country:US
Practice Address - Phone:718-292-9200
Practice Address - Fax:718-292-9205
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2015-11-13
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
NY147523174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00645987Medicaid
NYD47755Medicare UPIN
NYW4L491Medicare PIN
NY00645987Medicaid