1821051400 NPI number — DR. DEAN I BROWN OD

Table of content: DR. DEAN I BROWN OD (NPI 1821051400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821051400 NPI number — DR. DEAN I BROWN OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
DEAN
Provider Middle Name:
I
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1821051400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
380 S 3RD W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SODA SPRINGS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83276-1559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-547-2020
Provider Business Mailing Address Fax Number:
208-547-2114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 GATEWAY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCK SPRINGS
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82901-5782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-547-7153
Provider Business Practice Location Address Fax Number:
208-547-2060
Provider Enumeration Date:
04/06/2006

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:  6016TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 2902 AT , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 399T , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 100162 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: V2741 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010170301 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010170302 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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