Healthcare Provider Details

I. General information

NPI: 1669434361
Provider Name (Legal Business Name): PAYTON GORDON BROWN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 06/04/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 W BLAINE ST STE B
RIVERSIDE CA
92507-3970
US

IV. Provider business mailing address

1485 M 139
BENTON HARBOR MI
49022-5711
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4705
  • Fax: 513-584-7199
Mailing address:
  • Phone: 269-925-0585
  • Fax: 269-925-0070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01043159A
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: