Provider Demographics
NPI:1972594323
Name:BROWN, BRYAN DOUGLAS (OD)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:DOUGLAS
Last Name:BROWN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 GRACELAND DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-7347
Mailing Address - Country:US
Mailing Address - Phone:334-702-3937
Mailing Address - Fax:334-702-3938
Practice Address - Street 1:205 GRACELAND DR
Practice Address - Street 2:SUITE 1
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-7347
Practice Address - Country:US
Practice Address - Phone:334-702-3937
Practice Address - Fax:334-702-3938
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALR132TA436152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051529114OtherBCBS
AL009999105Medicaid
ALU73161Medicare UPIN
AL051529114OtherBCBS
051529114Medicare PIN
ALCN3942Medicare PIN