Provider Demographics
NPI:1972577385
Name:BROWN, DERYCK WINSTON SPENCER (MD)
Entity Type:Individual
Prefix:DR
First Name:DERYCK
Middle Name:WINSTON SPENCER
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:110 MAIN STREET
Practice Address - Street 2:
Practice Address - City:DUSHORE
Practice Address - State:PA
Practice Address - Zip Code:18614-0417
Practice Address - Country:US
Practice Address - Phone:570-928-8146
Practice Address - Fax:570-928-7488
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066159L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACC9269OtherRR MEDICARE GROUP
PAGU040074OtherMEDICARE GROUP
NY01860782Medicaid
PAGU039778OtherMEDICARE GROUP
PA0017018700001Medicaid
PA080176502OtherRR MEDICARE PIN
NY01860782Medicaid
PA080176502OtherRR MEDICARE PIN
PA017261N93Medicare ID - Type Unspecified