Provider Demographics
NPI:1760486294
Name:BROWN, HAROLD MORDECAI (DO)
Entity type:Individual
Prefix:
First Name:HAROLD
Middle Name:MORDECAI
Last Name:BROWN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:OH
Mailing Address - Zip Code:44827-1455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2003 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-1865
Practice Address - Country:US
Practice Address - Phone:567-307-7860
Practice Address - Fax:567-307-7861
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005482207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH080079622OtherRAILROAD MEDICARE
OH0882522Medicaid
OH000000012001OtherANTHEM
OH0715811Medicare ID - Type Unspecified
OH0882522Medicaid
OH000000012001OtherANTHEM