Basic Information
| Provider Information | |||||||||
| NPI: | 1235142159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1954 FT UNION BLVD | ||||||||
| Address2: | 107 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841216800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019939527 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4364 WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844031866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019939527 | ||||||||
| FaxNumber: | 8017335872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 06/05/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 174363-1205 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 101044100 | 05 | WY | MEDICAID | 39099 | 01 | UT | PEHP | OTHER | 870551783BR1 | 01 | UT | EDUCATORS MUTUAL | OTHER | PRA06170 | 01 | UT | MOLINA | OTHER | 4844 | 01 | UT | DESERET MUTUAL | OTHER | 52176 | 01 | UT | HEALTHY U | OTHER | QM0000050172 | 01 | UT | ALTIUS | OTHER | 107005254101 | 01 | UT | IHC | OTHER |