Healthcare Provider Details

I. General information

NPI: 1528254554
Provider Name (Legal Business Name): DOUGLAS E BROWN RT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 12/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1855 LAKELAND DR SUITE J10
JACKSON MS
39216-4913
US

IV. Provider business mailing address

1855 LAKELAND DR SUITE G10
JACKSON MS
39216-4913
US

V. Phone/Fax

Practice location:
  • Phone: 601-987-9425
  • Fax: 601-987-0093
Mailing address:
  • Phone: 601-987-9729
  • Fax: 601-987-0093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberMRT1971
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: