Provider Demographics
NPI:1952953515
Name:BROWN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2673 DEL MAR DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-1721
Mailing Address - Country:US
Mailing Address - Phone:970-640-0409
Mailing Address - Fax:970-248-3579
Practice Address - Street 1:2673 DEL MAR DR
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-1721
Practice Address - Country:US
Practice Address - Phone:970-640-0409
Practice Address - Fax:970-248-3579
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-14
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service