Basic Information
| Provider Information | |||||||||
| NPI: | 1750724555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | VIRGINIA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 480 ISLAND POINT DR | ||||||||
| Address2: | |||||||||
| City: | LAKE PROVIDENCE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712545318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182359043 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5000 HENNESSY BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708084375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257570552 | ||||||||
| FaxNumber: | 2257639997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2013 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 308567 | LA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2331060 | 05 | LA | MEDICAID |