Provider Demographics
NPI:1962409037
Name:BROWN, ROBERT THEODORE (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:THEODORE
Last Name:BROWN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 COOPER PLZ
Mailing Address - Street 2:SUITE 502
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1438
Mailing Address - Country:US
Mailing Address - Phone:856-342-2241
Mailing Address - Fax:856-968-7965
Practice Address - Street 1:3 COOPER PLZ
Practice Address - Street 2:SUITE 200
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1438
Practice Address - Country:US
Practice Address - Phone:856-342-2001
Practice Address - Fax:856-968-8206
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048098207QA0000X
PAMD013629E2080A0000X
NJMA087107002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64789233OtherMEDICAID
OH0498199Medicaid
NJMA08710700OtherSTATE LICENSE
WV0105237000OtherMEDICAID
NJMA08710700OtherSTATE LICENSE
OHBB0549521Medicare ID - Type Unspecified