1497751275 NPI number — DEAN RANDOLPH BROWN O.D.

Table of content: JACOB JACKS (NPI 1073316410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497751275 NPI number — DEAN RANDOLPH BROWN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
DEAN
Provider Middle Name:
RANDOLPH
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:
1497751275
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
650 E PINE ST
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
CENTRAL POINT
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97502-2482
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-664-5535
Provider Business Mailing Address Fax Number:
541-664-7745

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 E PINE ST
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
CENTRAL POINT
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97502-2482
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-664-5535
Provider Business Practice Location Address Fax Number:
541-664-7745
Provider Enumeration Date:
06/24/2005

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:  2302ATI , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 029715 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 807295000 . This is a "REGENCE BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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