Healthcare Provider Details

I. General information

NPI: 1154543569
Provider Name (Legal Business Name): JONATHAN M. BROWN, D.O., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 SOUTH HIGHWAY 95 SUITE M
FORT MOHAVE AZ
86426
US

IV. Provider business mailing address

4825 HIGHWAY 95 SUITE 5 #412
FORT MOHAVE AZ
96426
US

V. Phone/Fax

Practice location:
  • Phone: 928-788-4530
  • Fax:
Mailing address:
  • Phone: 928-788-4530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number4060
License Number StateAZ

VIII. Authorized Official

Name: LINA N DOEVE
Title or Position: MANAGER
Credential:
Phone: 928-788-4530