Provider Demographics
NPI:1902988512
Name:BROWN, BERTRAM MAXWELL (OD)
Entity type:Individual
Prefix:DR
First Name:BERTRAM
Middle Name:MAXWELL
Last Name:BROWN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 CARRIAGE HOUSE CT
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-4166
Mailing Address - Country:US
Mailing Address - Phone:804-822-1013
Mailing Address - Fax:
Practice Address - Street 1:306 CARRIAGE HOUSE CT
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-4166
Practice Address - Country:US
Practice Address - Phone:804-822-1013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000573152W00000X, 152WC0802X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009233237Medicaid
VA009233237Medicaid