MEDICARE: LARAE COLEMAN BROWN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	TRN12325	FL
2	207V00000X	Obstetrics & Gynecology Physician	ME112367	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780851980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARAE COLEMAN BROWN MD

Provider Business Mailing Address
First Line	:	15255 MAX LEGGETT PKWY STE 4400
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-7273
Country	:	US
Telephone Number	:	904-427-8898
Fax Number	:	904-383-1893

Provider Business Practice Location Address
First Line	:	15255 MAX LEGGETT PKWY STE 4400
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-7273
Country	:	US
Telephone Number	:	904-427-8898
Fax Number	:	904-383-1893

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2008
Last Update Date	:	09/13/2021

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