Basic Information
| Provider Information | |||||||||
| NPI: | 1669434361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | PAYTON | ||||||||
| MiddleName: | GORDON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1485 M 139 | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490225711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699250585 | ||||||||
| FaxNumber: | 2699250070 | ||||||||
| Practice Location | |||||||||
| Address1: | 769 W BLAINE ST STE B | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925073970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513584705 | ||||||||
| FaxNumber: | 5135847199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2006 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 01043159A | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 01043159A | 01 | IN | MD LICENSE - INDIANA | OTHER |