Provider Demographics
NPI:1841308103
Name:BROWN, OTTO WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:OTTO
Middle Name:WILLIAM
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 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:248-433-0881
Mailing Address - Fax:
Practice Address - Street 1:31700 TELEGRAPH RD
Practice Address - Street 2:SUITE 140
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-3407
Practice Address - Country:US
Practice Address - Phone:248-433-0881
Practice Address - Fax:248-433-1628
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010434962086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI020002993OtherMEDICARE RR
MI2115358Medicaid
MI020002993OtherMEDICARE RR
0631052Medicare ID - Type Unspecified