1598781007 NPI number — TRISTAN M BROWN O.D.

Table of content: TRISTAN M BROWN O.D. (NPI 1598781007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598781007 NPI number — TRISTAN M BROWN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
TRISTAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1598781007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 669
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARROLL
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51401-0669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-792-3318
Provider Business Mailing Address Fax Number:
712-792-3319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1236 HEIRES AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARROLL
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51401-3328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-792-3318
Provider Business Practice Location Address Fax Number:
712-792-3319
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  02359 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 25008 . This is a "WELLMARK JEFFERSON" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0498287 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 25005 . This is a "WELLMARK CARROLL" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 25007 . This is a "WELLMARK DENISON" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 250737 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 1498287 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 291300 . This is a "COVENTRY ALL OFFICES" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 2498287 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com