Basic Information
| Provider Information | |||||||||
| NPI: | 1033364674 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 CALIFORNIA ST | ||||||||
| Address2: | PO BOX 577 | ||||||||
| City: | CARTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619180577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185199200 | ||||||||
| FaxNumber: | 6189854635 | ||||||||
| Practice Location | |||||||||
| Address1: | 1506 N.SIOUX DR | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629595209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185199200 | ||||||||
| FaxNumber: | 6189859155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2008 | ||||||||
| LastUpdateDate: | 09/26/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036120519 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036120519 | 05 | IL | MEDICAID |