Basic Information
| Provider Information | |||||||||
| NPI: | 1417990565 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | REGINALD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1320 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430551822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2205644027 | ||||||||
| FaxNumber: | 2205644012 | ||||||||
| Practice Location | |||||||||
| Address1: | 1980 TAMARACK RD | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430551363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2205647520 | ||||||||
| FaxNumber: | 2205647521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 35091641 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 2889423 | 05 | OH | MEDICAID |