1679568984 NPI number — WILLARD MARTIN BROWN III DO

Table of content: WILLARD MARTIN BROWN III DO (NPI 1679568984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679568984 NPI number — WILLARD MARTIN BROWN III DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
WILLARD
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
DO
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:
1679568984
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 HUMPHREY LN
Provider Second Line Business Mailing Address:
102 HUMPHREY LANE
Provider Business Mailing Address City Name:
WEST SPRINGFIELD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01089-2282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-781-2287
Provider Business Mailing Address Fax Number:
413-732-4504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1985 MAIN ST
Provider Second Line Business Practice Location Address:
304
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01103-1095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-736-5491
Provider Business Practice Location Address Fax Number:
413-732-4504
Provider Enumeration Date:
09/13/2005

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: 207Q00000X , with the licence number:  38201 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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