Provider Demographics
NPI:1255538096
Name:BROWN, JASON EDWARD (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:EDWARD
Last Name:BROWN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3230
Mailing Address - Country:US
Mailing Address - Phone:307-856-6530
Mailing Address - Fax:
Practice Address - Street 1:1001 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3230
Practice Address - Country:US
Practice Address - Phone:307-856-6530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063733A2085R0202X
WY8042A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200868510Medicaid
INP00459733OtherRR MEDICARE
IN941090X5Medicare PIN
INP00459733OtherRR MEDICARE