Healthcare Provider Details

I. General information

NPI: 1073559704
Provider Name (Legal Business Name): MARY KATHRYN BROWN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 12/20/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9290 SE SUNNYBROOK BLVD SUITE 200
CLACKAMAS OR
97015-6899
US

IV. Provider business mailing address

9290 SE SUNNYBROOK BLVD SUITE 200
CLACKAMAS OR
97015-6899
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-1694
  • Fax: 503-659-8984
Mailing address:
  • Phone: 503-659-1694
  • Fax: 503-659-8984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD26080
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier278134
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: