Provider Demographics
NPI:1124079140
Name:BROWN, MICHAEL L (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
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:PO BOX 833
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:OR
Mailing Address - Zip Code:97495-0833
Mailing Address - Country:US
Mailing Address - Phone:541-673-2267
Mailing Address - Fax:
Practice Address - Street 1:2880 NW STEWART PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1202
Practice Address - Country:US
Practice Address - Phone:541-673-2267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6019799512085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0187354OtherLABOR AND INDUSTRIES
WA1109297Medicaid
OR034186Medicaid
OR034186Medicaid
WAGAB12190Medicare PIN
ORR161170Medicare PIN