Healthcare Provider Details

I. General information

NPI: 1407836117
Provider Name (Legal Business Name): MITCHELL BROWN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 C AVE
CORONADO CA
92118-1405
US

IV. Provider business mailing address

317 C AVE
CORONADO CA
92118-1405
US

V. Phone/Fax

Practice location:
  • Phone: 619-379-7221
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8934
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: