Healthcare Provider Details

I. General information

NPI: 1861976367
Provider Name (Legal Business Name): MISS INDYA DENISE BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 MERCER UNIVERSITY DR
MACON GA
31207-1515
US

IV. Provider business mailing address

104 KENT HILL CIR
ALABASTER AL
35007-5231
US

V. Phone/Fax

Practice location:
  • Phone: 478-301-4609
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberAT003342
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: