Provider Demographics
NPI:1891260618
Name:BROWN, MARK M
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 BARBERRY TER
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-4104
Mailing Address - Country:US
Mailing Address - Phone:585-353-9594
Mailing Address - Fax:
Practice Address - Street 1:184 BARBERRY TER
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-4104
Practice Address - Country:US
Practice Address - Phone:585-353-9594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYHAH1313172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver