Healthcare Provider Details

I. General information

NPI: 1093938276
Provider Name (Legal Business Name): KEISHA BROWN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 03/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4426 HUGH HOWELL RD STE. B-332
TUCKER GA
30084-4918
US

IV. Provider business mailing address

1304 ROCKBRIDGE RD STE. 4
STONE MOUNTAIN GA
30087-3138
US

V. Phone/Fax

Practice location:
  • Phone: 678-522-6086
  • Fax:
Mailing address:
  • Phone: 678-522-6086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number048985
License Number StateGA

VII. Legacy identifiers

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

# 1
Identifier832729777A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: