Basic Information
| Provider Information | |||||||||
| NPI: | 1770947483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | MASON | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BROWN | ||||||||
| OtherFirstName: | TONY | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3464 N 700 W | ||||||||
| Address2: | |||||||||
| City: | WABASH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469928782 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2605714682 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2900 W OKLAHOMA AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532154330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146496000 | ||||||||
| FaxNumber: | 4146495158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2016 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 73508-20 | WI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.