Healthcare Provider Details

I. General information

NPI: 1417058082
Provider Name (Legal Business Name): TIMOTHY MATHER BROWN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12612 SE STARK ST
PORTLAND OR
97233-1058
US

IV. Provider business mailing address

12612 SE STARK ST
PORTLAND OR
97233-1058
US

V. Phone/Fax

Practice location:
  • Phone: 503-257-6393
  • Fax: 503-257-8785
Mailing address:
  • Phone: 503-257-6393
  • Fax: 503-257-8785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD12786
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD12786
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberMD12786
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: