Provider Demographics
NPI:1770570236
Name:BROWN, BENNIE JR (DO)
Entity type:Individual
Prefix:DR
First Name:BENNIE
Middle Name:
Last Name:BROWN
Suffix:JR
Gender:M
Credentials:DO
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 1705
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30903-1705
Mailing Address - Country:US
Mailing Address - Phone:706-774-7263
Mailing Address - Fax:
Practice Address - Street 1:447 N BELAIR RD STE 101
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3091
Practice Address - Country:US
Practice Address - Phone:706-854-2222
Practice Address - Fax:706-854-2223
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18711207Q00000X
GA065085207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08636876Medicaid
GA003139672CMedicaid
GA202I088743Medicare PIN
GA003139672CMedicaid
MS08636876Medicaid