Basic Information
| Provider Information | |||||||||
| NPI: | 1912566753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 139 RITCHIE HWY STE B | ||||||||
| Address2: | |||||||||
| City: | SEVERNA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211461152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105447417 | ||||||||
| FaxNumber: | 4105444408 | ||||||||
| Practice Location | |||||||||
| Address1: | 139 RITCHIE HIGHWAY | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SEVERNA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105447417 | ||||||||
| FaxNumber: | 4105444408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2019 | ||||||||
| LastUpdateDate: | 06/06/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA2671 | MD | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | TA2671 | 01 | MD | LICENSE NUMBER | OTHER |