Healthcare Provider Details

I. General information

NPI: 1265545412
Provider Name (Legal Business Name): JERRY W BROWN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 01/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 HIGHWAY F
WAYNESVILLE MO
65583
US

IV. Provider business mailing address

1390 HIGHWAY F
WAYNESVILLE MO
65583
US

V. Phone/Fax

Practice location:
  • Phone: 573-774-2040
  • Fax: 573-774-6152
Mailing address:
  • Phone: 573-774-2040
  • Fax: 573-774-6152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT03398MO
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: