=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295836765
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIMOTHY M. BROWN, M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 12/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12612 SE STARK STREET
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97233-1058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-257-6393
-----------------------------------------------------
Fax | 503-257-8785
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12612 SE STARK STREET
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97233-1058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-257-6393
-----------------------------------------------------
Fax | 503-287-8785
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/BUSINESS OWNER
-----------------------------------------------------
Name | MR. TIMOTHY MATHER BROWN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 503-257-6393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ND0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207NS0135X
-----------------------------------------------------
Taxonomy Name | Procedural Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | MD12786
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207NS0135X
-----------------------------------------------------
Taxonomy Name | Procedural Dermatology Physician
-----------------------------------------------------
License Number | MD12786
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | MD12786
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------