Basic Information
| Provider Information | |||||||||
| NPI: | 1104995133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | HARRIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 NEWBURY PARK | ||||||||
| Address2: | |||||||||
| City: | NEEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024924218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814449352 | ||||||||
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| Practice Location | |||||||||
| Address1: | 280 WASHINGTON ST | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021353511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177837100 | ||||||||
| FaxNumber: | 6177837104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207N00000X | 59575 | MA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 3044459 | 05 | MA | MEDICAID |