Basic Information
Provider Information | |||||||||
NPI: | 1760445605 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROWN | ||||||||
FirstName: | ERIKA | ||||||||
MiddleName: | HOUSTON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | O.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HOUSTON | ||||||||
OtherFirstName: | ERIKA | ||||||||
OtherMiddleName: | LEIGH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1950 OLD GALLOWS RD | ||||||||
Address2: | 520 | ||||||||
City: | VIENNA | ||||||||
State: | VA | ||||||||
PostalCode: | 221823990 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7038478899 | ||||||||
FaxNumber: | 7039910514 | ||||||||
Practice Location | |||||||||
Address1: | 5615 S NC 41 HWY | ||||||||
Address2: |   | ||||||||
City: | WALLACE | ||||||||
State: | NC | ||||||||
PostalCode: | 284666216 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9102855050 | ||||||||
FaxNumber: | 9102852968 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2006 | ||||||||
LastUpdateDate: | 11/15/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1762 | NC | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 0925J | 01 | NC | BCBS PROV # | OTHER | 410048650 | 01 | NC | RR MEDICARE INDIVIDUAL # | OTHER | 890925J | 05 | NC |   | MEDICAID |