Basic Information
| Provider Information | |||||||||
| NPI: | 1245694595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | KASSANDRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100237 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326103001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522659522 | ||||||||
| FaxNumber: | 3522659575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1707 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326093650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522659522 | ||||||||
| FaxNumber: | 3522659575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2016 | ||||||||
| LastUpdateDate: | 07/22/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/28/2016 | ||||||||
| NPIReactivationDate: | 07/12/2017 | ||||||||
| ProviderGenderCode: | F | ||||||||
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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 | 207Q00000X | ME141006 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 103401800 | 05 | FL | MEDICAID |