Provider Demographics
NPI:1245015643
Name:BROWN, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 LORETO LN
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004-8365
Mailing Address - Country:US
Mailing Address - Phone:614-804-2192
Mailing Address - Fax:
Practice Address - Street 1:712 LORETO LN
Practice Address - Street 2:
Practice Address - City:BLACKLICK
Practice Address - State:OH
Practice Address - Zip Code:43004-8365
Practice Address - Country:US
Practice Address - Phone:614-804-2192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist