Healthcare Provider Details

I. General information

NPI: 1063431716
Provider Name (Legal Business Name): CRYSTAL LYNN BROWN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 BLUEBIRD BLVD
FORT VALLEY GA
31030-5085
US

IV. Provider business mailing address

701 BLUEBIRD BLVD
FORT VALLEY GA
31030-5085
US

V. Phone/Fax

Practice location:
  • Phone: 478-827-1971
  • Fax: 478-827-1973
Mailing address:
  • Phone: 478-827-1971
  • Fax: 478-827-1973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036348
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: