Basic Information
| Provider Information | |||||||||
| NPI: | 1790746873 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844555 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022844555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578895422 | ||||||||
| FaxNumber: | 7578895450 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 KINGSLEY LN | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235054617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042626900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 04/06/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0101052191 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 7240619 | 05 | VA | MEDICAID |