Healthcare Provider Details

I. General information

NPI: 1619954633
Provider Name (Legal Business Name): ERIC BROWN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 N GRAND AVE
GLENDORA CA
91741-2434
US

IV. Provider business mailing address

148 N GRAND AVE
GLENDORA CA
91741-2434
US

V. Phone/Fax

Practice location:
  • Phone: 626-594-0478
  • Fax: 626-594-0575
Mailing address:
  • Phone: 626-594-0478
  • Fax: 626-594-0575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number200201222
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA72839
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier89132J9
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: