Provider Demographics
NPI:1255429379
Name:BROWN, BRANDON (PT)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2270 DOUGLAS BLVD STE 216
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4239
Mailing Address - Country:US
Mailing Address - Phone:916-782-1212
Mailing Address - Fax:
Practice Address - Street 1:20996 REDWOOD RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5918
Practice Address - Country:US
Practice Address - Phone:510-537-0272
Practice Address - Fax:510-537-5819
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011036225100000X
CA291488225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00844093OtherMEDICARE RR
ILF400173376Medicare PIN
IL216859032Medicare PIN
IL202845310Medicare PIN
IL214708001Medicare PIN
IL216860006Medicare PIN