Provider Demographics
NPI:1053383786
Name:BROWN, THOMAS LARRY SR (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:LARRY
Last Name:BROWN
Suffix:SR
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 1:200 NORTHCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4440
Mailing Address - Country:US
Mailing Address - Phone:850-932-9404
Mailing Address - Fax:850-932-5707
Practice Address - Street 1:200 NORTHCLIFF DR
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4440
Practice Address - Country:US
Practice Address - Phone:850-932-9404
Practice Address - Fax:850-932-5707
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00007599207U00000X
FLME232932085R0202X
VA0101-0211302085R0202X, 2085R0202X
NY2304292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069260300Medicaid
FL069260300Medicaid
VA015097C19Medicare PIN
VAP00427596Medicare PIN
FL00017335BMedicare ID - Type Unspecified