Basic Information
| Provider Information | |||||||||
| NPI: | 1043470040 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 E DAWSON ST | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035314262 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2008 | ||||||||
| LastUpdateDate: | 09/11/2015 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | P0174 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 75-2616977-001 | 01 | TX | TRICARE | OTHER | 8CW707 | 01 | TX | BCBS | OTHER | 283578703 | 05 | TX | MEDICAID | 750818167048 | 01 | TX | TRICARE | OTHER | 750818167015 | 01 | TX | TRICARE | OTHER | 8CX225 | 01 | TX | BCBS | OTHER | 75-0818167-044 | 01 | TX | TRICARE | OTHER | 75-2616977-028 | 01 | TX | TRICARE | OTHER | 283578701 | 05 | TX | MEDICAID | 283578702 | 05 | TX | MEDICAID | 283578704 | 05 | TX | MEDICAID | 75-0818167-022 | 01 | TX | TRICARE | OTHER | 75-2616977-002 | 01 | TX | TRICARE | OTHER | 751976930005 | 01 | TX | TRICARE | OTHER | 8EZ186 | 01 | TX | BCBS | OTHER | 8EZ185 | 01 | TX | BCBS | OTHER |