Provider Demographics
NPI:1912008095
Name:BROWN, JOHN BARCLAY III (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BARCLAY
Last Name:BROWN
Suffix:III
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 1:700 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3046
Mailing Address - Country:US
Mailing Address - Phone:208-882-4511
Mailing Address - Fax:
Practice Address - Street 1:700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3056
Practice Address - Country:US
Practice Address - Phone:208-883-6246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7435207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805170800Medicaid
ID080125280OtherRAILROAD MEDICARE
ID1139182Medicare ID - Type Unspecified
IDG69133Medicare UPIN