Provider Demographics
NPI:1548374887
Name:BROWN, DANIEL R
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
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:PO BOX 2025
Mailing Address - Street 2:101 N 16TH ST
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-5225
Mailing Address - Country:US
Mailing Address - Phone:618-988-6034
Mailing Address - Fax:618-988-6479
Practice Address - Street 1:101 N 16TH STREET
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948
Practice Address - Country:US
Practice Address - Phone:618-988-6034
Practice Address - Fax:618-988-6479
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004890213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004890Medicaid
IL016004890Medicaid
IL4497790001Medicare NSC
200547Medicare PIN