Basic Information
Provider Information | |||||||||
NPI: | 1346275575 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROWN | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1400 EMELINE AVE | ||||||||
Address2: |   | ||||||||
City: | SANTA CRUZ | ||||||||
State: | CA | ||||||||
PostalCode: | 950601976 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8314544900 | ||||||||
FaxNumber: | 8314544663 | ||||||||
Practice Location | |||||||||
Address1: | 1400 EMELINE AVE | ||||||||
Address2: | 1ST FLOOR | ||||||||
City: | SANTA CRUZ | ||||||||
State: | CA | ||||||||
PostalCode: | 950601976 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8314544900 | ||||||||
FaxNumber: | 8314544663 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 04/04/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | C50186 | CA | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | C50186 | CA | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
ID | Type | State | Issuer | Description | BP970X | 01 | CA | INDIVIDUAL MEDICARE PTAN# | OTHER | BP970Z | 01 | CA | INDIVIDUAL MEDICARE PTAN# | OTHER | 00C501860 | 05 | CA |   | MEDICAID | C50186 | 01 | CA | MEDICAL LICENSE# | OTHER | BB4017326 | 01 | CA | DEA LICENSE # | OTHER | ZZZ91892Z | 01 | CA | MEDICARE GROUP ID# | OTHER | ZZZ92069Z | 01 | CA | MEDICARE GROUP ID# | OTHER | ZZZ91891Z | 01 | CA | MEDICARE GROUP ID# | OTHER |