Provider Demographics
NPI:1154543569
Name:JONATHAN M. BROWN, D.O., P.C.
Entity type:Organization
Organization Name:JONATHAN M. BROWN, D.O., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINA
Authorized Official - Middle Name:N
Authorized Official - Last Name:DOEVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-788-4530
Mailing Address - Street 1:4825 HIGHWAY 95
Mailing Address - Street 2:SUITE 5 #412
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:96426
Mailing Address - Country:US
Mailing Address - Phone:928-788-4530
Mailing Address - Fax:
Practice Address - Street 1:5300 SOUTH HIGHWAY 95
Practice Address - Street 2:SUITE M
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426
Practice Address - Country:US
Practice Address - Phone:928-788-4530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4060207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ878209Medicaid
AZ878209Medicaid
AZZ83060Medicare ID - Type Unspecified