=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043391808
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLETTE K BROWN-GRAHAM M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 07/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12955 PALMS WEST DR STE 101
-----------------------------------------------------
City | LOXAHATCHEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33470-9212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-792-0050
-----------------------------------------------------
Fax | 561-792-0048
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1397 MEDICAL PARK BLVD SUITE 360
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-3188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-792-0050
-----------------------------------------------------
Fax | 561-792-0048
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 71561
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | 71561
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------