Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | 16772 | KY |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 16772 | KY |
NPI | 1114052677 |
---|---|
Provider Name | Manuel L Brown JR. |
First Address | Louisville, KY 40212-1033 |
Second Address | Fairdale, KY 40118-9697 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/02/2007 |
Last Update Date | 05/05/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
64167729 | (05) | KY |
C71306 | (02) | KY |