Basic Information
| Provider Information | |||||||||
| NPI: | 1518305945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7700 WASHINGTON VILLAGE DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375310195 | ||||||||
| FaxNumber: | 9375310196 | ||||||||
| Practice Location | |||||||||
| Address1: | 7700 WASHINGTON VILLAGE DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454594094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375310195 | ||||||||
| FaxNumber: | 9375310196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2013 | ||||||||
| LastUpdateDate: | 11/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | 34.011770 | OH | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0296428 | 05 | OH | MEDICAID |