Provider Demographics
NPI:1982604880
Name:BROWN, MARK R (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:BROWN
Suffix:
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 1:442 STACHLER DR
Mailing Address - Street 2:P.O. BOX 308
Mailing Address - City:ST HENRY
Mailing Address - State:OH
Mailing Address - Zip Code:45883-9582
Mailing Address - Country:US
Mailing Address - Phone:419-678-2371
Mailing Address - Fax:419-678-4783
Practice Address - Street 1:442 STACHLER DR
Practice Address - Street 2:
Practice Address - City:ST HENRY
Practice Address - State:OH
Practice Address - Zip Code:45883-9582
Practice Address - Country:US
Practice Address - Phone:419-678-2371
Practice Address - Fax:419-678-4783
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34 005329207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0931782Medicaid
OH0234455OtherMEDICAID GROUP
OH9282991OtherMEDICARE GROUP
OHBR0737155Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
OH0234455OtherMEDICAID GROUP
OH0931782Medicaid
OH9282992Medicare PIN