Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 036096380 | IL |
Y | 207N00000X | Dermatologist | 4301093918 | MI |
N | 207ND0101X | MOHS-Micrographic Surgeon | 036096380 | IL |
N | 207ND0101X | MOHS-Micrographic Surgeon | 4301093918 | MI |
N | 207NS0135X | Procedural Dermatology | 036096380 | IL |
N | 207NS0135X | Procedural Dermatology | 4301093918 | MI |
NPI | 1386654390 |
---|---|
Provider Name | Dr. Clarence W. Brown JR. |
First Address | Saint Joseph, MI 49085-3203 |
Second Address | Saint Joseph, MI 49085-3203 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2006 |
Last Update Date | 06/01/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0360963803 | (05) | IL |
1386654390 | (05) | MI |
911779986 | TAX ID (01) | IL |
G99335 | (02) | IL |