Basic Information
Provider Information
NPI: 1033557657
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BROWN
FirstName: CLAYTON
MiddleName: J
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 731912
Address2:  
City: DALLAS
State: TX
PostalCode: 753731912
CountryCode: US
TelephoneNumber: 9038777777
FaxNumber:  
Practice Location
Address1: 11937 US HIGHWAY 271
Address2:  
City: TYLER
State: TX
PostalCode: 757083154
CountryCode: US
TelephoneNumber: 9038777200
FaxNumber: 9038775080
Other Information
ProviderEnumerationDate: 06/05/2013
LastUpdateDate: 06/05/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000XBP10046117TXY Allopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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