Healthcare Provider Details

I. General information

NPI: 1104302157
Provider Name (Legal Business Name): KENNETH STEPHAN BROWN MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 ROSS AVE
EL CENTRO CA
92243-4306
US

IV. Provider business mailing address

210 N TUSTIN AVE
SANTA ANA CA
92705-3807
US

V. Phone/Fax

Practice location:
  • Phone: 760-339-7100
  • Fax:
Mailing address:
  • Phone: 714-347-1000
  • Fax: 714-647-1245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG70912
License Number StateCA

VIII. Authorized Official

Name: DR. KENNETH BROWN
Title or Position: PRESIDENT
Credential: MD
Phone: 714-347-1000