Provider Demographics
NPI:1124348842
Name:BROWN, DEREK MATTHEW (DO)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:MATTHEW
Last Name:BROWN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1761 BEALL AVE
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-2342
Mailing Address - Country:US
Mailing Address - Phone:330-263-8763
Mailing Address - Fax:330-263-8190
Practice Address - Street 1:1761 BEALL AVE
Practice Address - Street 2:SUITE 3B
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2342
Practice Address - Country:US
Practice Address - Phone:330-462-7001
Practice Address - Fax:330-263-8169
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.010738207RC0200X, 207RP1001X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0077411Medicaid
OH0077411Medicaid