Provider Demographics
NPI:1982871299
Name:BROWN, BENJAMIN S (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:S
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 1:103 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-2812
Mailing Address - Country:US
Mailing Address - Phone:706-647-5683
Mailing Address - Fax:706-647-9651
Practice Address - Street 1:503 W GORDON ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3424
Practice Address - Country:US
Practice Address - Phone:706-938-4483
Practice Address - Fax:773-342-5781
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14894174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA14891OtherLICENSE
GAAB6679596OtherDEA
GAD44934Medicare UPIN