Provider Demographics
NPI:1548309362
Name:BROWN, EDWARD IVAN (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:IVAN
Last Name:BROWN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 GRIDER STREET
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3021
Mailing Address - Country:US
Mailing Address - Phone:716-986-9199
Mailing Address - Fax:716-986-9180
Practice Address - Street 1:501 TENTH STREET
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14301-1800
Practice Address - Country:US
Practice Address - Phone:716-278-4418
Practice Address - Fax:716-284-7188
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1599632208000000X
NY159963208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00010201001OtherUNIVERA
NY00967840Medicaid
NY1203556OtherIHA
NY000510044005OtherBC BS CB
NYJ400047495Medicare PIN
NY1203556OtherIHA
C59369Medicare UPIN