Healthcare Provider Details

I. General information

NPI: 1164404109
Provider Name (Legal Business Name): T L BROWN OD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 07/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 E LINCOLNWAY ST
JEFFERSON IA
50129-2107
US

IV. Provider business mailing address

PO BOX 460
JEFFERSON IA
50129-0460
US

V. Phone/Fax

Practice location:
  • Phone: 515-386-8196
  • Fax: 515-386-2380
Mailing address:
  • Phone: 515-386-8196
  • Fax: 515-386-2380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: TERRY L BROWN
Title or Position: PRESIDENT
Credential: O.D.
Phone: 515-386-8196