Basic Information
| Provider Information | |||||||||
| NPI: | 1003817537 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | SPIERS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1866 N ORANGE GROVE AVE | ||||||||
| Address2: | STE 102 | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096204373 | ||||||||
| FaxNumber: | 9096207179 | ||||||||
| Practice Location | |||||||||
| Address1: | 1866 N ORANGE GROVE AVE | ||||||||
| Address2: | STE 102 | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096204373 | ||||||||
| FaxNumber: | 9096207179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | G304546 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G304560 | 05 | CA | MEDICAID | AB6616001 | 01 | DEA | OTHER |