Healthcare Provider Details

I. General information

NPI: 1467414714
Provider Name (Legal Business Name): THEODORE ROBERT BROWN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 03/28/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LANDSTUHL REGIONAL MEDICAL CENTER UNIT 33100
APO AE
09180
US

IV. Provider business mailing address

195 CANARY DR
ELIZABETHTOWN KY
42701-8553
US

V. Phone/Fax

Practice location:
  • Phone: 270-969-8136
  • Fax:
Mailing address:
  • Phone: 270-969-8136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number02002352A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02002352A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number02002352A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: