Healthcare Provider Details

I. General information

NPI: 1427330299
Provider Name (Legal Business Name): RODDRICK GRAYLIN BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2011
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 NORMANDY BLVD
JACKSONVILLE FL
32205-6253
US

IV. Provider business mailing address

5820 NORMANDY BLVD
JACKSONVILLE FL
32205-6253
US

V. Phone/Fax

Practice location:
  • Phone: 904-786-6047
  • Fax: 904-786-6436
Mailing address:
  • Phone: 904-786-6047
  • Fax: 904-786-6436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberB650727790980
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: