Provider Demographics
NPI:1942276605
Name:BROWN, LARRY D SR (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:D
Last Name:BROWN
Suffix:SR
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 1:301 WALNUT RUN ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-9729
Mailing Address - Country:US
Mailing Address - Phone:409-384-1495
Mailing Address - Fax:409-383-1214
Practice Address - Street 1:301 WALNUT RUN ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-9729
Practice Address - Country:US
Practice Address - Phone:409-384-1495
Practice Address - Fax:409-383-1214
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0083GNOtherBCBS
TX133131601Medicaid
TX133161610Medicaid
TX133131601Medicaid
TXE53322Medicare UPIN