1164404109 NPI number — T L BROWN OD PC

Table of content: (NPI 1164404109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164404109 NPI number — T L BROWN OD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
T L BROWN OD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JEFFERSON EYE CARE, P.C.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164404109
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 460
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50129-0460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-386-8196
Provider Business Mailing Address Fax Number:
515-386-2380

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 E LINCOLNWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50129-2107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-386-8196
Provider Business Practice Location Address Fax Number:
515-386-2380
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
515-386-8196

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4210471460 . This is a "HUMANA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0792242 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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