Basic Information
Provider Information | |||||||||
NPI: | 1356513261 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BREWSTER | ||||||||
FirstName: | EARL | ||||||||
MiddleName: | MARK | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4930 E LAKE MARY BLVD | ||||||||
Address2: |   | ||||||||
City: | SANFORD | ||||||||
State: | FL | ||||||||
PostalCode: | 327715003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073228645 | ||||||||
FaxNumber: | 4073305074 | ||||||||
Practice Location | |||||||||
Address1: | 4930 E LAKE MARY BLVD | ||||||||
Address2: |   | ||||||||
City: | SANFORD | ||||||||
State: | FL | ||||||||
PostalCode: | 327715003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073228645 | ||||||||
FaxNumber: | 4073305074 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2008 | ||||||||
LastUpdateDate: | 06/08/2016 | ||||||||
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 | 207V00000X | ME126781 | FL | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | ME126781 | 01 | FL | STATE LICENSE | OTHER | FB2601070 | 01 | FL | DEA | OTHER | 017069700 | 05 | FL |   | MEDICAID |