Provider Demographics
NPI:1063431716
Name:BROWN, CRYSTAL LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:LYNN
Last Name:BROWN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 BLUEBIRD BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-5085
Mailing Address - Country:US
Mailing Address - Phone:478-827-1971
Mailing Address - Fax:478-827-1973
Practice Address - Street 1:701 BLUEBIRD BLVD
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-5085
Practice Address - Country:US
Practice Address - Phone:478-827-1971
Practice Address - Fax:478-827-1973
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036348207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00554111AMedicaid
GA08BDGCQMedicare ID - Type Unspecified
GA00554111AMedicaid